Memorial Hospital is excited to introduce Memorial Junior Medical School (MJMS), a new career exploration program for high school students. The MJMS will be a two day program offered for two sessions over the summer. The students will work with a variety of health care professionals and gain valuable insight into the careers offered within the industry. Activities include working with the School of Radiology, clinical simulation lab and students will receive their CPR/AED certification. This packet includes the application and the counselor recommendation form. Please read through all materials carefully before applying. The application for the summer program is due to the Youth Programs Coordinator by Wednesday, April 15, 2015, no exceptions. For questions or additional information, please contact the Memorial Hospital Volunteer Services Department at 365-5298. *All applicants must be current high school juniors or seniors, recommended by a counselor and have a GPA of 3.0 or higher. Application Check List ___ A signed and completed application ___ Completed recommendation form from your high school counselor ___ $15 application fee* Mail to: Volunteer Services Department Memorial Hospital Central 1400 E. Boulder Street Colorado Springs, CO 80909 * If selected, there will be an additional $60 program fee. Memorial Hospital will provide one scholarship for an eligible candidate. Applicants will receive written notification in the mail regarding the status of their application shortly after the deadline. Incomplete applications or applications received after the deadline will not be considered. Memorial Junior Medical School Application (Please print or type) Please check which session you are applying for: Session 1- June 15th and 16th: _______ Session 2 - July 23rd and 24th: _______ Name ________________________________________________________________________________________ Last First Middle Initial Email Address _______________________________________________ Mailing Address _________________________________________________________________________________ Street City Zip Cell Phone _________________________ Home Phone __________________________ Date of Birth ______/_______/______ M _____ F _____ Name of High School __________________________________________________________________________ Current Grade Level this Semester ________________ GPA _________ What are you career goals? ________________________________________________________________ ______________________________________________________________________________________ What steps have you taken towards these goals? _______________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________ Do you have any volunteer or work experience related to health care? *Applications must be received by the deadline, April 15, 2015. Waiver: I certify that the above facts are complete and accurate to the best of my knowledge. I also understand that any false statements may be cause for immediate dismissal from the program. I acknowledge that there are risks involved in my participation in the program above and hereby agree to hold harmless Memorial Hospital its trustees, officers, directors, employees, representatives and agents from any claim, damage, illness or loss whatsoever that I may experience, including any physical or emotional injury, as a result of my participation in this or related programs. Applicant’s Signature (required) Date Parental Consent: My son or daughter has my permission and full support to participate in the Memorial Junior Medical School program at Memorial Hospital, University of Colorado Health. I understand if the application is incomplete or turned in late it will NOT be considered. I understand the risks associated with my child’s participation. Parent or Guardian’s Signature (required) Date Memorial Junior Medical School Student Recommendation Form Applicant’s name Please complete this form to nominate the above student for Memorial Hospital’s MJMS career exploration program. This section to be filled out by a high school counselor: PLEASE PRINT Counselor: School: Phone: Why do you recommend this student for the MJMU program? Has the student shown a high level of interest in pursuing a healthcare career? Is the student dependable? Do they follow through with commitments? Please comment on the student’s social skills? Are they comfortable communicating with a diverse population? Has the student had any disciplinary issues? Is there any reason you can give why the applicant should not participate? Additional Comments: Signature: ______________________________________________________ Date: ________________________________ *PLEASE RETURN THE FORM TO THE STUDENT TO TURN IN WITH THEIR APPLICATION.