Future HealthCare Professionals Application
FHP is a health career exploration program open to high school students in the area. The Summer 2023 Hardin County FHP program will be held in-person 3:00-4:30 pm, July 5, 6 ,7, 12, 13, 14, 19, 20, 21 at the Hardin County Public Library. Throughout the program, students will explore different areas of the healthcare field through hands-on activities and meeting with guest speakers. Applications are due June 26, 2023.
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Name: *
Preferred Name (If Different)
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 #: *
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