2025 Scrubs Camp Application

Please email Kathleen Couch at kathleen.couch@kctcs.edu, Shayla Pratt at spratt0006@kctcs.edu, or Melissa Perry at mperry0036@kctcs.edu or you may call (606)487-0135 or (606)226-3108 with questions.

ATTENTION!!!!! Before you begin this application you will need an official transcript and a copy of a health insurance card to upload.

You will not be able to save the information and return to work on this application at a later time.

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* 1. Student Information

First Name

Last Name

Mailing Address

City

State

Zip Code

Date of Birth (dd/mm/yyyy)

Last 4 Digits of SSN

Phone Number

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* 2. What is your gender?

Female

Male

Other (specify)

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* 3. What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Another race or ethnicity, please describe below

Self-describe below:

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* 4. Please select which camp you wish to attend:

Bell (6/24/25-6/25/25)

Breathitt (7/8/25)

Clay (7/15/25-7/16/25)

Floyd (6/9/25-6/10/25)

Harlan (7/10/25-7/11/25)

Perry (6/12/25 -6/13/25)

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* 5. School Information

School

GPA

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* 6. Current Grade Level:

Current 8th

Current 9th

Current 10th

Current 11th

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* 7. Shirt Size

Adult Small

Adult Medium

Adult Large

Adult XLarge

Adult 2XLarge

Adult 3XLarge

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* 8. List Any Extracurricular Activities that you are currently involved. (Clubs, Dance, Sports)

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* 9. List any Summer Enrichment Programs or Summer Camps that you have attended. Be sure to include any other health career camps.

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* 10. List any Community Activities that you are a part of. (Church, Civic Organizations, Volunteer, Etc. )

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* 11. List any Honors or Awards you have received.

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* 12. Parent/Guardian Information

Parent/Guardian Name

Relation to Student

Email Address

Phone Number

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* 13. Media Release Statement (please choose one)

By checking this box, I am giving my permission to use my child's photograph and/or name for promotion of and publicity pertaining to their participation in the 2024 Health Careers Camp. Entities include Southeast KY AHEC, UK Center for Rural Health, ARH and Southeast Community and Technical College. I am aware that my child’s name and photograph could be released to the local media which could include, but not be limited to, newspapers, radio, social media and television.

I do not wish for my child’s name or photograph to be used for publicity and/or promotion of
the Southeast KY AHEC’s Summer Camp in any way.

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* 14. By completing the names below, both student and parent are acknowledging the application to the camp.

Student Name

Parent Name

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* 15. Please upload your official transcript below:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 16. Please upload a copy of your health insurance card.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

2025 Scrubs Camp Application

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* 1. Student Information

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* 2. What is your gender?

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* 3. What is your race or ethnicity?

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* 4. Please select which camp you wish to attend:

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* 5. School Information

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* 6. Current Grade Level:

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* 7. Shirt Size

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* 8. List Any Extracurricular Activities that you are currently involved. (Clubs, Dance, Sports)

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* 9. List any Summer Enrichment Programs or Summer Camps that you have attended. Be sure to include any other health career camps.

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* 10. List any Community Activities that you are a part of. (Church, Civic Organizations, Volunteer, Etc. )

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* 11. List any Honors or Awards you have received.

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* 12. Parent/Guardian Information

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* 13. Media Release Statement (please choose one)

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* 14. By completing the names below, both student and parent are acknowledging the application to the camp.

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* 15. Please upload your official transcript below:

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* 16. Please upload a copy of your health insurance card.

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* 17. Please list any dietary restrictions or food allergies.