A five week summer enrichment program for 11th grade students from
Vermont interested in health careers.
What is the purpose of CollegeQuest?
The purpose of CollegeQuest is get students who are interested in careers in health care and health sciences
ready to succeed in college. Students work on their college application, financial aid plans, and career goals.
Students who complete the program will receive 3.0 college credits from Vermont Technical College (VTC) and
a $1,500 stipend to use toward college expenses.
What does CollegeQuest cost?
There is no cost to attend CollegeQuest. Housing, meals, recreation and all program materials are provided.
Where and when does CollegeQuest take place?
CollegeQuest takes place on the Randolph, VT, campus of Vermont Technical College from Sunday, July 12th
through Saturday, August 15th, 2015. Students stay in the resident halls on campus throughout the program.
All meals during the program are provided. Activities take place Monday through Saturday at VTC and at other
locations throughout Vermont. Sundays are a free day for students to relax, entertain visitors or leave campus
with family for the day. Students must arrange their own transportation to and from the program.
Who is eligible to apply for CollegeQuest?
Applicants must be in the 11th grade and live in Vermont. Eligible applicants will either be of modest income,
or have parents with less than a four-year degree. Having successfully completed biology is a perquisite for
attendance. Applicants must commit to attending the entire 5-week program.
How is CollegeQuest supervised?
CollegeQuest is led by the professional staff of the Vermont AHEC Network who specialize in developing and
conducting youth programs in health careers exploration. Contributing faculty come from the Vermont Student
Assistance Corporation (VSAC) and from Vermont colleges. Health professionals and policy makers are
featured guest speakers. Supervision is provided throughout the 5-week program by full-time resident
assistance staff.
How do I apply?
Fill out the enclosed application and have it in our office by THURSDAY, MARCH 19, 2015. Your application
must be complete in order to be considered. (This includes the 2 completed reference forms.)
For more information contact:
Laura Remick, Program Director, at (877) 215-3921 (toll free),
Email: lremick @nevahec.org or visit our website at nevahec.org
Northeastern Vermont Area Health Education Center (AHEC)
347 Emerson Falls Road, Suite 3, St. Johnsbury, VT 05819
APPLICATION FORM
**Due by Thursday, March 19, 2015**
This is a competitive application. Please provide your best work and have the
completed application to the Northeastern Vermont AHEC office on or before the deadline.
We recommend having a VSAC or Guidance Counselor review your application before submission.
Personal Information:
Name: _____________________________________________________________________________
First
Middle Initial
Last
Mailing Address: _____________________________________________________________________
Street or P.O. Box
City/State
Phone: _____________________________
Gender:
 Male  Female
Zip Code
Birth date: mm / dd / yyyy
Student’s E-mail Address: ___________________________________
Name of the school you are presently attending: _____________________________________________
Are you currently in 11th grade?
 Yes  No
Does one or both of your parents have a 4 year college degree?
 Yes
 No
Do you or anyone in your household qualify for free or reduced lunch?
 Yes
 No
Do you have a VSAC Counselor?
 Yes
 No
Will any of your family members need an English translator to participate in the orientation sessions?
 Yes
 No
If yes, please let us know your family member’s native language for us to best accommodate you:
___________________________________________________________________
How did you hear about CollegeQuest to Health Careers? (Please check all that apply.)
 Friend
 From a CollegeQuest completer
 School Staff ________________________________
(Example: teacher, nurse or guidance, VSAC)
 Parent / guardian
 AHEC Website / AHEC staff
 Other __________________________________
Students who successfully complete this program will receive a $1500 stipend and 3.0 college credits
from Vermont Technical College. Food and housing are provided to participants throughout program.
All books and materials are provided.
Eligible students must be either low-income (100% FPL) or the child of parents with less than a four
year degree. If we need further clarification about your eligibility we will contact you.
Vermont Area Health Education Center Network
CollegeQuest to Health Careers
Page 1 of 3
References:
With this packet there are two reference forms to be completed. One of these references must be an adult,
other than your parent, who knows how you learn and interact in a group, like a teacher, coach or a camp
counselor. We recommend that your second reference be a community member or an adult that knows you
outside of school.
Please list below the two people you have asked to fill out reference forms:
Name: __________________________________ Title: _________________________ Phone number: _________________
Name: __________________________________ Title: _________________________ Phone number: _________________
PLEASE NOTE: Your references MUST mail their forms back to us directly.
Do not include any completed reference forms with your CollegeQuest application. They will not be accepted.
You are responsible for making sure your references send their forms to AHEC on or before the
application deadline. You will be notified by email when we have received your application and
references. Please check your email on a regular basis.
A)
Please list all the science courses you have taken in high school. (Please note: Biology is a prerequisite
for qualification.)
B)
Please list your education goals after high school. If you are interested in a particular health care field,
please tell us what it is and why?
For questions C & D, type out your responses on a seperate sheet of paper. Do not exceed one page per
question.
C)
CollegeQuest to Health Careers is a 5-week summer program away from home, family and friends;
it requires a real commitment on your part. Describe the benefits that you see from participating
in this enrichment program. Please also describe any challenges that you see.
D) Please describe and discuss any experiences you have had that have sparked your interest in health careers.
(Examples: volunteer activities, tech center programs, after school programs in the health care field, MedQuest,
personal or family events, job shadows, etc.) How have these experiences inspired your interests? What
strengths or qualities from your experiences will you bring to CollegeQuest to Health Careers?
Vermont Area Health Education Center Network
CollegeQuest to Health Careers
Page 2 of 3
I certify that the information given in this application is true and correct. I have proofread for accuracy
and completeness. I understand that applications are accepted only when complete.
Signature of applicant: _____________________________________________ Date: _____________________
TO BE COMPLETED BY PARENT OR GUARDIAN:
Name of parent or guardian: _____________________________________________________________________
I give permission for ____________________________________________ to attend the 2015 CollegeQuest
to Health Careers enrichment program.
I understand that this is a 5-week residential program (July 12 - August 15, 2015) at Vermont Technical College
in Randolph, Vermont. I support my student’s application to this program. If accepted, I will support my child’s
full participation.
I agree to provide a copy of my 2014 federal tax return to determine eligibility for my student if requested. I
understand that any information I or my child provides is held strictly confidential.
A mandatory pre-orientation meeting for students and parents will be scheduled at 4 different locations
throughout the state; please choose one session that works best for your family.
___Thursday, April 23, 2015, 6 to 8 PM, Lyndon Institute, Lyndonville, VT
___Sunday, April 26, 2015, 2 pm to 4 PM, Red School House, Vermont Technical College, Randolph, VT
___Tuesday, April 28, 2015, 6 to 8 PM, Albany College of Pharmacy and Health Science, Colchester, VT
___Thursday, April 30, 2015, 6 to 8 PM, at the Southern Vermont AHEC office, Springfield, VT
Signature of parent or guardian: ________________________________________ Date: ____________________
Please have the completed application to the AHEC office
at the address below by
THURSDAY, MARCH 19, 2015.
Please allow 2 to 3 days for the postal service to deliver your application to:
CollegeQuest to Health Careers
Northeastern Vermont AHEC
347 Emerson Falls Road, Suite 3
St. Johnsbury, VT 05819
Vermont Area Health Education Center Network
CollegeQuest to Health Careers
Page 3 of 3
CONFIDENTIAL STUDENT REFERENCE
July 12 - August 15, 2015
(To be completed by at least ONE teacher and ONE of the following:
a health professional, school counselor, mentor, community or spiritual leader.)
Applicant’s name: ____________________________________________
School: ___________________________________________________
This student is applying to attend the Vermont Area Health Education Center (AHEC) Network’s CollegeQuest to Health Careers, a
5-week summer residential program at Vermont Technical College in Randolph. The purpose of CollegeQuest to Health Careers is to
provide college preparation and academic enrichment for students interested in careers in health care and health sciences. To the best
of your knowledge, please assess this applicant’s abilities.
APPLICANT’S STRENGTHS as you see them:
APPLICANT’S CHALLENGES as you see them:
Do you feel the applicant has the interpersonal skills and abilities to succeed in a five-week residential academic enrichment program with
peers?
Yes ___
No____
Don’t know___
PLEASE RANK THE APPLICANT IN THE FOLLOWING AREAS. If you do not have experience with the applicant in an area, please circle N/A.
Highest
___
Lowest
LEADERSHIP SKILLS
(Ability to make good choices, work effectively with others, etc.)
5
4
3
2
1
N/A
INTEREST LEVEL IN SCIENCES
(Academic and extra-curricular activities related to science)
5
4
3
2
1
N/A
VERBAL SKILLS and EXPRESSION
(Ability to communicate effectively)
5
4
3
2
1
N/A
INTERPERSONAL SKILLS
(Ability to get along and share space with others)
5
4
3
2
1
N/A
MOTIVATION
(Interest in strengthening academic and college preparation skills)
5
4
3
2
1
N/A
MATURITY
(Responsibility, adaptability, respectfulness)
5
4
3
2
1
N/A
SUMMARY COMMENTS: Please provide an overall impression of the applicant and any additional comments.
Evaluator’s Name: _____________________________________________ Signature: ____________________________________________
Occupation and/or relationship to student: ______________________________________________________________________________
Date: ___________________ Work Phone Number: ____________________________ Email ______________________________________
Completed Confidential Student Reference Forms must be submitted separately and directly by the evaluator.
References included with the student’s CollegeQuest application will not be accepted.
Please scan & email or snail-mail this form to our office by: THURSDAY, MARCH 19, 2015.
CollegeQuest to Health Careers, Northeastern VT AHEC, 347 Emerson Falls Road, Suite 3, St. Johnsbury, VT 05819
Questions? Contact Laura Remick, Program Director, at (877) 215-3921 (toll free) or [email protected]
CONFIDENTIAL STUDENT REFERENCE
July 12 - August 15, 2015
(To be completed by at least ONE teacher and ONE of the following:
a health professional, school counselor, mentor, community or spiritual leader.)
Applicant’s name: ____________________________________________
School: ___________________________________________________
This student is applying to attend the Vermont Area Health Education Center (AHEC) Network’s CollegeQuest to Health Careers, a
5-week summer residential program at Vermont Technical College in Randolph. The purpose of CollegeQuest to Health Careers is to
provide college preparation and academic enrichment for students interested in careers in health care and health sciences. To the best
of your knowledge, please assess this applicant’s abilities.
APPLICANT’S STRENGTHS as you see them:
APPLICANT’S CHALLENGES as you see them:
Do you feel the applicant has the interpersonal skills and abilities to succeed in a five-week residential academic enrichment program with
peers?
Yes ___
No____
Don’t know___
PLEASE RANK THE APPLICANT IN THE FOLLOWING AREAS. If you do not have experience with the applicant in an area, please circle N/A.
Highest
___
Lowest
LEADERSHIP SKILLS
(Ability to make good choices, work effectively with others, etc.)
5
4
3
2
1
N/A
INTEREST LEVEL IN SCIENCES
(Academic and extra-curricular activities related to science)
5
4
3
2
1
N/A
VERBAL SKILLS and EXPRESSION
(Ability to communicate effectively)
5
4
3
2
1
N/A
INTERPERSONAL SKILLS
(Ability to get along and share space with others)
5
4
3
2
1
N/A
MOTIVATION
(Interest in strengthening academic and college preparation skills)
5
4
3
2
1
N/A
MATURITY
(Responsibility, adaptability, respectfulness)
5
4
3
2
1
N/A
SUMMARY COMMENTS: Please provide an overall impression of the applicant and any additional comments.
Evaluator’s Name: _____________________________________________ Signature: ____________________________________________
Occupation and/or relationship to student: ______________________________________________________________________________
Date: ___________________ Work Phone Number: ____________________________ Email ______________________________________
Completed Confidential Student Reference Forms must be submitted separately and directly by the evaluator.
References included with the student’s CollegeQuest application will not be accepted.
Please scan & email or snail-mail this form to our office by: THURSDAY, MARCH 19, 2015.
CollegeQuest to Health Careers, Northeastern VT AHEC, 347 Emerson Falls Road, Suite 3, St. Johnsbury, VT 05819
Questions? Contact Laura Remick, Program Director, at (877) 215-3921 (toll free) or [email protected]