2026 Scrubs Camp Application Survey

1.Student Information(Required.)

First Name

Last Name

Mailing Address

City

State

Zip Code

Date of Birth (mm/dd/yyyy)

Last 4 Digits of SSN

Email

Phone

2.What is your gender?

Female

Male

Other (specify)

3.What is your race or ethnicity?

Self-describe below:

4.Please select which camp you wish to attend:(Required.)

5.School Information(Required.)

School

GPA

6.Current Grade Level:(Required.)

Current 8th

Current 9th

Current 10th

Current 11th

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

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

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

11.List any Honors or Awards you have received.(Required.)

12.Parent/Guardian Information(Required.)

Parent/Guardian Name

Relation to Student

Email Address

Phone Number

13.Media Release Statement (please choose one)(Required.)

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.

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

Student Name

Parent Name

15.Please upload your official transcript below:(Required.)

No file chosen

16.Please upload a copy of your health insurance card.(Required.)

No file chosen

17.Please list any dietary restrictions or food allergies.