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YMCA Health Career Achievers Application

Please complete the form below to submit your application to YMCA Health Careers Achievers Program.

Full Name

Gender

male

female

Birthdate

Phone number

Street address

City

State

ZIP code

Mailing address (only if different from above)

Name of current school

Current GPA

Grade entering in August

9th

10th

11th

12th

Email address

Emergency contact info

First and last name

Phone number

Relationship to student

About you

List of extracurricular activities

What do you plan to do after high school?

Get a job (do not check if you plan to work for the summer)

Go to a two-year college

Go to a four-year college/university

Undecided

Other

Career interests

Athletic Trainer

Certified Nursing Assistant

Chiropractor

Dentist / Dental Hygenist

EMT / Paramedic

Health Administration

Licensed Practical Nurse

Medical Assistant

Medical Lab Tech

Medical Transcriptions

Nurse Anesthetist

Nurse Practitioner

Occupational Therapist

Optometrist

Pharmacist

Pharmacy Technician

Physical Therapist

Podiatrist

Psychologist

Radiology Technician

Registered Nurse

Researcher

Respiratory Therapist

Ultrasound Technician

Veterinarian

Other

Personal essay

Why do you want to attend HealthCare Explorers? What are your future career goals and how do you plan to achieve them?

Attendance

At this time, are you able to commit to attending these sessions?

Yes

No

If you selected ''No'', please describe the circumstances that will prevent full attendance.

Parent / Guardian info

Parent / Guardian name (first and last)

Cell Phone (include area code)

Parent/guardian Email address

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Disclaimer: All research and clinical material published by Wake Forest School of Medicine on its site is for informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider. Wake Forest School of Medicine will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising therefrom.

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