Application Form ~ Deadline: Friday, February 9, 2018
School year completed by June 2018
Please list your top 3 activities — athletic, artistic, community, musical, etc. — in the order of their importance to you.
Number of Years
Positions, Awards or Levels Achieved
Choose one activity and briefly discuss how your participation has contributed to your growth.
List 3 places where you have been employed and/or done volunteer work, your responsibilities, the duration, and contact information for each work or volunteer experience.
Choose one work or volunteer experience and briefly discuss how your participation has contributed to your growth.
Do you speak another language in addition to English?
Please complete the following sentences:
My three greatest strengths are:
Three areas of improvement for me would be:
Three areas of the healthcare field that interest me the most include:
Have you ever been convicted of a crime? (A conviction will not bar you from consideration in this program.)
If yes, please explain:
Is there any circumstance which might limit your participation during the HEP program?
If yes, please explain:
I certify that all information given is true to the best of my knowledge and that the short essay questions are not plagiarized nor written by someone else on my behalf (Assistance with composition and proofreading is acceptable.) I understand that, if selected to participate in HEP, I will be required to submit to an alcohol/drug test.
I understand that if selected my child/ward will participate in observation-only clinical rotations in real patient care settings, receive education regarding medical subjects and clinical situations that may be graphic, and receive information regarding health-related issues and the circumstances contributing to those issues. I understand that if selected to participate in HEP, my child/ward will be required to submit to an alcohol/drug test. I do hereby consent to my child’s/ward’s participation in the CHRISTUS St. Vincent Healthcare Exploration Program.
Write one fully developed paragraph response to each of the following questions or statements. Be mindful to write with attention to clear, specific content as well as grammar. Although you are most welcome to get assistance with organizing your thoughts and proofreading, the final work must be your own and you should be prepared to discuss your answers should you be chosen for an interview.
1. Why should you be chosen for this program?
2. If you could select one area of Health Care to focus on in this program, what would that be and why?
3. Explain an ethical dilemma you have had experience with and what your response to the dilemma was.
4. Should you be selected for this program, what do you hope to get from participating? What can we expect you to contribute?
Media Consent Form ~ Deadline: Friday, February 9, 2018
For publicity, promotional, advertising, printed, or educational material I hereby consent to being photographed, filmed, and/or interviewed by St. Vincent Hospital Foundation and CHRISTUS St. Vincent. I hereby give my permission that these photographs, films, and information may be used as follows:
IN THE EVENT YOU ARE SELECTED TO PARTICIPATE
I understand that photographs, film/videotape, and/or interviews are intended for public viewing and I consent to the use and release of my identity.
For radio, television and/or print media
You will need a Teacher Recommendation and a Personal Recommendation. Please have a teacher, and someone who is not a teacher or relative, click on the appropriate links below and fill out the electronic form.
You will also need your school's registrar to upload your school records to this site. Just have your parent(s)/guardian(s) fill out the downloadable PDF consent form (below), give it to the registrar and have them upload your records using the link below.
Teacher Recommendation Form Area
Personal Recommendation Form Area
Registrar Consent Form
Registrar Form Area