application-2015-kearney-conference1

2015 BHECN High School Ambassador Conference Application Form April 10-11, 2015 in Kearney, Nebraska (Please Print Clearly) High school: located in _ (town/city) Student’s Full Name: Name as you want it to appear on name tags, certificates, etc _ Mailing Address: _ City NE Zip Student’s Cell phone: ( _ ) _ Gender: male female Grade: junior Expected graduation: _ / _ mm / yyyy ETHNICITY: Hispanic/Latino yes Nebraska County: _ Is it okay to text to this number? yes no senior Birth Date: _/ / _ m m/ d d / y y y y no RACE:  White / Caucasian  Asian Please specify:  Black / African American  Native Hawaiian or Pacific Islander  Native American or Alaskan Native  other: _ Student school e-mail: Student personal e-mail: Parent/Guardian’s E-mail Address(es): (Circle all that apply) 1) When application is received, send confirmation to: school e-mail personal e-mail parental e-mail no e-mail needed 2) Send electronic acceptance and conference details to: school e-mail personal e-mail parental e-mail no e-mail needed Please circle T-shirt size: (adult sizes) Large (42-44) X Large (46-48) 1|Page Small (34-36) Medium (38-40) XX Large (50-52) XXX Large (54-56) (PERSONAL INFORMATION PROVIDED BELOW WILL BE TREATED CONFIDENTIALLY) yes no 1) Will student need lodging on Friday, April 10? (BHECN can provide double occupancy lodging for students who are traveling to attend this conference.) yes no 2) Are there any special dietary needs and/or vegetarian meals requested? Please describe: yes no 3) Does the student have any health concerns or allergies: Please describe: yes no 4) Does the student take any medication on a regular basis? If yes: • Please list medication(s), dosage(s) and times needed: _ • Does medication need to be refrigerated? • Does the student need assistance to administer the medication? yes yes no no If yes, please provide instructions: yes no 5) If the student will be sleeping at the hotel in Kearney, does student have any sleep disorders? Please describe: yes no 6) Are there any other health concerns or issues we should know about? yes no 7) If selected to attend the conference, parents/guardians want contact information shared with other parents from the area to try to coordinate travel arrangements? If yes, please provide information that can be printed and shared: Contact name(s) Phone(s) E-mail(s) Check list for application packet: _ complete application form (all pages) _ media release form /emergency contact information is signed by parent/guardian _ personal essay (explained on page 3) _ letter of recommendation from principal or teacher or school counselor Space is limited Complete application packet must be postmarked, faxed or scanned by February 13, 2015 Mail to: Ann Kraft, BHECN Ambassador Conference Behavioral Health Education Center of Nebraska 984242 Nebraska Medical Center Omaha, NE 68198-4242 FAX (402) 552-7699 2|Page Questions? Contact Ann at (402) 552-7638 or akraft@unmc.edu 3|Page 1) Please complete the following: Name of Profession Have you heard of this career? Is this a career you are considering? case manager yes no yes no not sure counselor yes no yes no not sure marriage and family therapist yes no yes no not sure peer support specialist yes no yes no not sure physician assistant yes no yes no not sure psychiatric nurse practitioner yes no yes no not sure psychiatrist yes no yes no not sure psychologist yes no yes no not sure social worker yes no yes no not sure substance abuse counselor yes no yes no not sure 2) Personal Essay On a separate sheet of paper, • Describe in 1-2 paragraphs why you are interested in attending this conference and what you hope to gain from the event • Describe the size and type of community where you hope to live and work someday and why that appeals to you • Be sure your name is listed in the title of the essay Be complete but clear and concise 3) Attach a letter of recommendation from a high school principal, teacher or guidance counselor describing what makes you a good candidate for this conference (career goals, maturity, leadership positions, school involvement, etc.) 4|Page 2015 BHECN High School Ambassador Conference Parent/Guardian Authorization & Media Consent Form Student’s Name: I/We, the parents or guardians of the above named student, hereby grant approval for him/her to participate in any and all activities for the 2014 BHECN Ambassador Conference to be held April 10-11, 2015 in Kearney, Nebraska I/We assume all risks and hazards accidental to such participation including transportation to and from activities in Kearney I/We give permission to the conference coordinator, Ann Kraft, to arrange for emergency treatment or admittance to a health care facility, or any other medical action deemed necessary under the circumstances I understand that I/we will be notified as soon as possible in the event of an emergency I/We further understand that the Behavioral Health Education Center of Nebraska and the University of Nebraska Medical Center are not responsible for injury that may result from accidents Print name X Parent/Guardian Signature date In case of emergency please contact: Name: ( ) Daytime phone ( ) Evening phone Name: ( ) Daytime phone Relationship: ( ) Cell phone Relationship: ( ) Evening phone ( ) Cell phone Media Release Authorization In the interest of education and the advancement of the health sciences, I, the undersigned, voluntarily authorize the University of Nebraska Medical Center and its employees and agents to take photographs, produce newspaper or magazine articles, television programs, videotape recordings, and other visual and/or audio recordings in which the above named minor may be included in whole or in part I understand that this information may be released to hometown newspapers, local national/media, or posted on the Web I grant this authorization and give my consent as a voluntary contribution to the advancement of medical and other health sciences and education Therefore, I waive the following: (1) any proprietary rights in the materials; and (2) any right I may have to inspect or approve the finished materials prior to publication I release the University of Nebraska Medical Center and its employees and agents from any claims arising from the use of such materials X _ Signature of Parent/Legal Guardian Date 5|Page