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Application and Contract for the Primary Health Care Program APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY: STUDENT LAST NAME: STUDENT FIRST NAME: DATE OF BIRTH: I UNDERSTAND AND AGREE TO FULFILL THE FOLLOWING CONDITIONS OF MY ENROLLMENT IN THE PRIMARY HEALTH CARE PROGRAM, ADMINISTERED BY IMPACT INSTITUTE. 1. Student must have passed ISTEP+/End of Course Assessment for English Language Arts. 2. Student must be entering his/her junior or senior year of high school. 3. Student must have an interest in Nursing. 4. Parent(s)/Guardian(s) permission is required for admittance to the program. 5. If your high school does not provide transportation, you must have your own reliable transportation for travel to clinical rotations. 6. Student must follow state guidelines including a required amount of clinical hours. Meeting the hour requirement may involve attending a scheduled day off. 7. Student must follow a dress code. Uniforms will be purchased through the program. 8. Student must report absence to instructor. 9. Student must demonstrate a professional attitude. 10. Strict patient confidentiality is important. Failure to comply will result in removal from the program. 11. Student will do all clinical rotations in the long-term care facility or nursing home with vocational instructor. 12. Student must demonstrate excellent attendance; poor attendance will result in your inability to earn your certification. I HAVE READ AND UNDERSTAND THE ABOVE CONDITIONS OF MY ENROLLMENT. Student Signature (Required) Date Parent Signature (Required) Date Guidance Counselor Signature (Required) Date IMPACT Institute has a policy of providing equal opportunity. All courses are open to students regardless of race, color, gender, disabilities or national origin, including limited English proficiency.

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Page 1: Primary Health Care Application - Impact Institute · Primary Health Care Additional Application Materials APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY: Please submit a COMPUTER

Application and Contract for the Primary Health Care Program

APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY:

STUDENTLASTNAME: STUDENTFIRSTNAME: DATEOFBIRTH: IUNDERSTANDANDAGREETOFULFILLTHEFOLLOWINGCONDITIONSOFMYENROLLMENTINTHEPRIMARYHEALTHCAREPROGRAM,ADMINISTEREDBYIMPACTINSTITUTE.

1. StudentmusthavepassedISTEP+/EndofCourseAssessmentforEnglishLanguageArts.2. Studentmustbeenteringhis/herjuniororsenioryearofhighschool.3. StudentmusthaveaninterestinNursing.4. Parent(s)/Guardian(s)permissionisrequiredforadmittancetotheprogram.5. Ifyourhighschooldoesnotprovidetransportation,youmusthaveyourownreliabletransportationfor

traveltoclinicalrotations.6. Studentmustfollowstateguidelinesincludingarequiredamountofclinicalhours.Meetingthehour

requirementmayinvolveattendingascheduleddayoff.7. Studentmustfollowadresscode.Uniformswillbepurchasedthroughtheprogram.8. Studentmustreportabsencetoinstructor.9. Studentmustdemonstrateaprofessionalattitude.10. Strictpatientconfidentialityisimportant.Failuretocomplywillresultinremovalfromtheprogram.11. Studentwilldoallclinicalrotationsinthelong-termcarefacilityornursinghomewithvocational

instructor.12. Studentmustdemonstrateexcellentattendance;poorattendancewillresultinyourinabilitytoearnyour

certification.IHAVEREADANDUNDERSTANDTHEABOVECONDITIONSOFMYENROLLMENT. StudentSignature(Required) Date ParentSignature(Required) Date GuidanceCounselorSignature(Required) Date

IMPACT Institute has a policy of providing equal opportunity. All courses are open to students regardless of race, color, gender, disabilities or national origin, including limited English proficiency.

Page 2: Primary Health Care Application - Impact Institute · Primary Health Care Additional Application Materials APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY: Please submit a COMPUTER

Primary Health Care Teacher Reference Form

APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY:

TEACHER: STUDENT NAME: CLASS: SCHOOL: Please provide the information requested concerning this student. He/she is applying for a position in the Primary Health Care program. All information will remain confidential. Thank you for your cooperation. Please return this reference form to the guidance department. Always

3 Most Often

2 Infrequently

1 Never

0 1. The student is reliable and responsible 2. This student shows respect and concern for others. 3. This student’s communication skills are appropriate. 4. This student participates in class and is attentive. I would would not recommend this student for Primary Health Care. Please include comments about this student: Teacher Signature: Date:

Page 3: Primary Health Care Application - Impact Institute · Primary Health Care Additional Application Materials APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY: Please submit a COMPUTER

Primary Health Care Additional Application Materials

APPLICATION FOR ENROLLMENT DUE TO GUIDANCE OFFICE BY:

Please submit a COMPUTER GENERATED response to the following questions and attach to your application. Each question must be answered in full.

1. What qualities do you think are valuable for a health care worker to possess?

2. What do you think the term confidentiality means and how would you demonstrate this while in the Primary Health Care program?

3. Describe some duties you think will be involved in the Primary Health Care class.

4. While performing duties related to the Primary Health Care program, how would you conduct

yourself professionally?

5. What makes you unique from other applicants to the program?

6. What plans do you have following graduation? What health care careers are you interested in?

7. Do you have any health experience? Please explain.

8. If you are accepted into the program, what do you expect to gain?

9. Has anyone influenced your decision to apply to the program? If so, who is that person and in what way?

10. What are your thoughts and feelings on the elderly?

11. What questions do you have regarding the program?

In addition to your COMPUTER GENERATED responses to the above questions, you must also include the following:

Ø Vocational Enrollment Application Ø Primary Health Care Application and Contract Ø High School Transcript, including English Language Arts End of Course Assessment Ø Attendance Record Ø Three (3) completed teacher reference forms

APPLICATIONS WILL NOT BE CONSIDERED IF ANY OF THE ABOVE MATERIALS ARE MISSING


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