MJMS Application 2015

Memorial Hospital is excited to introduce Memorial Junior Medical School (MJMS), a new career exploration
program for high school students. The MJMS will be a two day program offered for two sessions over the
summer. The students will work with a variety of health care professionals and gain valuable insight into the
careers offered within the industry. Activities include working with the School of Radiology, clinical
simulation lab and students will receive their CPR/AED certification.
This packet includes the application and the counselor recommendation form. Please read through all materials
carefully before applying. The application for the summer program is due to the Youth Programs Coordinator by
Wednesday, April 15, 2015, no exceptions. For questions or additional information, please contact the
Memorial Hospital Volunteer Services Department at 365-5298.
*All applicants must be current high school juniors or seniors, recommended by a counselor and have a GPA of
3.0 or higher.
Application Check List
___ A signed and completed application
___ Completed recommendation form from your high school counselor
___ $15 application fee*
Mail to: Volunteer Services Department
Memorial Hospital Central
1400 E. Boulder Street
Colorado Springs, CO 80909
* If selected, there will be an additional $60 program fee. Memorial Hospital will provide one scholarship for
an eligible candidate.
Applicants will receive written notification in the mail regarding the status of their application shortly after the
deadline. Incomplete applications or applications received after the deadline will not be considered.
Memorial Junior Medical School Application
(Please print or type)
Please check which session you are applying for: Session 1- June 15th and 16th: _______
Session 2 - July 23rd and 24th: _______
Name ________________________________________________________________________________________
Last
First
Middle Initial
Email Address _______________________________________________
Mailing Address _________________________________________________________________________________
Street
City
Zip
Cell Phone _________________________
Home Phone __________________________
Date of Birth ______/_______/______
M _____ F _____
Name of High School __________________________________________________________________________
Current Grade Level this Semester ________________
GPA _________
What are you career goals? ________________________________________________________________
______________________________________________________________________________________
What steps have you taken towards these goals?
_______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________
Do you have any volunteer or work experience related to health care?
*Applications must be received by the deadline, April 15, 2015.
Waiver: I certify that the above facts are complete and accurate to the best of my knowledge. I also understand
that any false statements may be cause for immediate dismissal from the program.
I acknowledge that there are risks involved in my participation in the program above and hereby agree to hold
harmless Memorial Hospital its trustees, officers, directors, employees, representatives and agents from any claim,
damage, illness or loss whatsoever that I may experience, including any physical or emotional injury, as a result of
my participation in this or related programs.
Applicant’s Signature (required)
Date
Parental Consent: My son or daughter has my permission and full support to participate in the Memorial Junior Medical
School program at Memorial Hospital, University of Colorado Health. I understand if the application is incomplete or
turned in late it will NOT be considered. I understand the risks associated with my child’s participation.
Parent or Guardian’s Signature (required)
Date
Memorial Junior Medical School
Student Recommendation Form
Applicant’s name
Please complete this form to nominate the above student for Memorial Hospital’s MJMS career exploration
program.
This section to be filled out by a high school counselor: PLEASE PRINT
Counselor:
School:
Phone:
Why do you recommend this student for the MJMU program?
Has the student shown a high level of interest in pursuing a healthcare career?
Is the student dependable? Do they follow through with commitments?
Please comment on the student’s social skills? Are they comfortable communicating with a diverse population?
Has the student had any disciplinary issues?
Is there any reason you can give why the applicant should not participate?
Additional Comments:
Signature: ______________________________________________________ Date: ________________________________
*PLEASE RETURN THE FORM TO THE STUDENT TO TURN IN WITH THEIR APPLICATION.