Future HealthCare Professionals - a health career exploration program
FHP is a health career exploration program open to high school students in the area. The Summer 2024 FHP program will be held in-person from 9 am - 12 pm on July 15, 16, 17, 18, and 22nd, 23rd, 24th, and 25th at the Warren County Public Library - Lisa Rice Branch. Throughout the program, students will explore different areas of the healthcare field through hands on activities and meeting with guest speakers. Application is due by 6/14. Emails regarding program details will be sent at the end of June.
Sign in to Google to save your progress. Learn more
Section 1 -- Student Information
We are grant funded and this information is needed for our grant reports.
Name: *
County: *
Gender: *
Email: *
Cell Phone: *
Home Phone:
Race (select all that apply):
This program is supported by WKU/AHEC. Collection of the following information is a requirement of this grant.
Ethnicity: *
This program is supported by WKU/AHEC. Collection of the following information is a requirement of this grant.
Last 4 digits of social security number
Birthday
MM
/
DD
/
YYYY
Parent/Guardian Information
Parent/Guardian Name: *
Address:
City:
Zip code:
Phone Number: *
We will use this number in the event of an emergency
Alternative Phone Number: *
Email: *
Emergency Contact
In the event of an emergency, we will contact the parent/guardian listed above. If, however, we can not reach that person, we will contact the below emergency contact.
Alternative Emergency Contact Name: *
Emergency Contact Relation *
Emergency Contact Phone #: *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms