Copy of Breathitt Co. Scrubs Camp Application

Breathitt Co. Scrubs Camp will be held on 7/11/2023 at the Ky River Medical Center

If you have questions regarding this camp, please contact Ashley Farler at (606)487-0135 or afarler0007@kctcs.edu.

Application Deadline: 5/26/2023

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* 1. Student Information

First Name

Last Name

Mailing Address

City

State

Zip Code

Date of Birth (dd/mm/yyyy)

Email Address

Phone Number

Last 4 Digits of SSN

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* 2. School Information

School

GPA

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* 3. Current Grade Level:

Current 8th

Current 9th

Current 10th

Current 11th

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* 4. Shirt Size

Adult Small

Adult Medium

Adult Large

Adult XLarge

Adult 2XLarge

Adult 3XLarge

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

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

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* 8. List and Honors or Awards you have received.

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* 9. What Healthcare Profession are you most interested in?

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* 10. Parent/Guardian Information

Parent/Guardian Name

Relation to Student

Email Address

Phone Number

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

Student Name

Parent Name