Providing Rural Opportunities in Medicine through Inspiring Service and Education

September, 2016

Dear Counselors and Educators:

Project PROMISE will be awarding internships for the Spring & Fall 2017 semester of the 2017 academic school year to 6 high school seniors who are enrolled at a qualifying high school. The program is designed for students who are participating in a school-sanctioned internship program. Project PROMISE began in 2014 and has evolved to become more community and internship-focused, using as a model the MAHEC-sponsored Minority Medical Mentoring Program. Today, the program pairs minority high school students with physicians, pharmacists, dentists, and other health care providers practicing in qualifying counties.

To be eligible for consideration for this internship, students must have a minimum weighted grade point average of 3.0, qualify as a socioeconomically underprivileged student, and have a strong desire to pursue a career as a healthcare provider, including but not limited to; dentist, pharmacist, physician, physical therapist, physician’s assistant, or nurse practitioner, have an active record of work and/or community service and access to reliable transportation.

If you have students who are interested in pursuing one of the above-mentioned careers and may be interested in this program, please share the enclosed information. We are looking for

students who are excited about a career in health care, are mature, responsible and focused, need minimal supervision, must be dependable, practice good oral and written communication skills, and have an excellent attitude and personality.

This program is a collaborative effort of the Center for Rural Health Innovation (CRHI), the Mountain Area Health Education Center (MAHEC), UNC School of Medicine and the Western Carolina Medical Society (WCMS). Thank you in advance for your assistance in identifying and recruiting students that will benefit from this program.

The deadline for submission of this application is November 11th, 2016. If you have any additional questions, please do not hesitate to contact us:

Project PROMISESteering Committee

CRHI BoardJacquelyn HallumMiriam SchwartzSteve North, MDRivers WoodwardBrittany Papworth

Bryan McClure

Student Name: ________________________________________________________________

For internal use onlyDate received: __________________________________

Project PROMISE

A Collaboration of: Center for Rural Health Innovation (CRHI) UNC School of Medicine Mountain Area Health Education Center (MAHEC) Western Carolina Medical Society (WCMS)

All information will be held in strictest confidentiality. Please type or print your responses attaching additional pages as necessary.

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Application Deadline (application must be received by):

November 11th, 2016

Return completed packet to your career counselor:

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Student Name: ________________________________________________________________

Project PROMISE Program Overview

Project PROMISE began in the fall of 2014 as an enrichment program for students interested in pursuing a career in healthcare. Today, the program pairs driven high school students with dentists, pharmacists, physicians, physical therapists, and others practice in the students’ home county. The Project PROMISE Internship is designed for students enrolled in high schools in qualifying counties who are participating in a school-sanctioned internship program. This program provides a minimum of 135 credit hours for one semester.

We are extremely thankful for the time and efforts of the program preceptors who provide leadership for the internship experience and allow students to have a hands-on and minds-on experience.

The students selected for this program will be rising high school seniors who are excited about a career in dentistry, pharmacy, medicine, or physical therapy, are mature, responsible and focused, need minimal supervision, must be dependable, practice good oral and written communication skills, and possess an excellent personality and attitude.

Did you know that every rural county in WNC is considered a Health Professional Shortage Area? This means that there is a great need for healthcare professionals to take care of the aging population in these counties. Rural areas have higher rates of preventable diseases and need healthcare providers that are both excellent clinicians and passionate community leaders. It has been shown that the most influential factor in determining who will eventually practice in a rural area is where or not an individual grew up rural themselves. This is why we are encouraging and supporting high school students from qualifying high schools such as yours to take on responsibility for the future health of their communities.

Our state is in dire need of more skilled healthcare practitioners practicing in our rural counties. We hope that by giving students this unique experience, they will eventually come back to practice in Western North Carolina and that we as a community are taking positive steps toward achieving health parity in Western North Carolina.

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THE EXPERIENCE:Student interns are scheduled weekly rotations with participating physicians, pharmacists, dentists, physical therapists and other health care practitioners the students’ home county. They are exposed to a variety of healthcare disciplines, such as anesthesiology, dentistry, dermatology, family medicine, geriatrics, integrative medicine, internal medicine, obstetrics and gynecology, optometry, palliative care, pharmacotherapy, physical medicine, public health, radiology, and more. The rotations will take place in clinics, hospitals, private practices, and education centers. In addition to scheduled rotations, students may use internship hours to participate in MAHEC’s health career programs that include academic enrichment, college preparation, conferences, service learning opportunities, public speaking, leadership and presentation skills. Students are expected to work together to create a presentation on a health-related issue pertinent to their community to be presented at the end of their internship. Each student is also assigned a leadership mentor who provides guidance and coaching during the internship.

A week-long student orientation includes program overview and expectations, training on the Health Information Portability and Accountability Act (HIPAA), Occupational Safety and Health Administration (OSHA), diversity and workplace etiquette, group project requirements, internship grading rubric, and orientation to MAHEC Library and Knowledge Services.

INTERNSHIP SCHEDULE:Students wishing to participate in Project PROMISE should enroll in their school’s internship program for the last period of the day and the last available lunch. This will enable the student to have a rotation schedule from 2:30–4:30 pm.

LIABILITY INSURANCE:Students enrolled in the internship program are covered under their school’s liability coverage. Verification of the school’s liability coverage must be provided to MAHEC prior to the start of the program.

Eligibility Requirements Socioeconomically under-resourced

o First generation college applicant OR combined household income < $100,000/yr Rising high school senior enrolled in a qualifying high school Strong desire to pursue a career in healthcare, i.e.; physician, pharmacist, physical

therapist, dentist, physician’s assistant, or nurse practitioner Minimum weighted grade point average of 3.0 Excellent references, based on teacher recommendation Active record of work and/or community service Access to reliable transportation

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Must have access to reliable transportation

Student Application Form

Please select the semester in which you would like to participate in the internship program: Spring 2017 Fall 2017

Student Information:

_____________________________________________________________________________________________Last name First name Middle name Nickname _____________________________________________________________________________________________Street address/P. O. Box City State Zip code County

Race/Ethnicity:

_____ Black or African American _____ Hispanic or Latino _____ More than one race ____ Caucasian _____ American Indian or Alaskan Native _____ Native Hawaiian or Other Pacific Islander_____ Asian Underrepresented (Bangladeshi, Cambodian, Hmong, Indonesian, Laotian, Malaysian, Nepalese, Pakistani, Sri Lankan and Vietnamese): please specify: _________________________________________

Did one or both parents graduate from a four-year college? Yes____ No____

Please circle your parents’ estimated combined household income below:< $30,000 $30,000-$60,000 > $60,000

Gender: ____________ Date of Birth: _______________ Last 4 digits of SSN: _______________

Graduation year: ________ Home telephone number: (____) _____-______Cell: (____) _____-________

Email address: _______________________________________________________________________

__________________________________________________________ (______)________-________Name of school City School Telephone number __________________________________________________________ (______)________-________Parent/Guardian name Place of work Work Telephone number

__________________________________________________________ (______)________-________Parent/Guardian name Place of work Work telephone number

Parent/Guardian Email: ____________________________ Evening/cell phone: _________________

___________________ (______) _______-__________Name of school official who recommended you (Please print) Telephone number

SIGNATURES: I am in full support of _____________________________ participating in the Project PROMISE Internship.

(Name of student)

Student Signature _______________________________________________________________ Date _____________

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Parent Signature ________________________________________________________________ Date ______________

Parent Signature ________________________________________________________________ Date ______________

Student Application Form: Page 2

Please type or print your responses attaching additional pages as necessary.

Student name: _____________________________________________________________________

PERSONAL STATEMENT OF CAREER GOALS: Describe in detail why you would like to participate in Project PROMISE. Let us know about your educational and career goals.

WORK EXPERIENCE, ACTIVITIES, AWARDS, HONORSList all awards, honors, community and school activities in which you have participated including beginning and end dates and number of hours of participation. Attach an additional sheet if necessary. Include sports, student government, volunteer projects, paid employment, and other activities you believe helped you to grow and contribute during your time as a high school student. Please note those activities that you are currently involved in.

Dates/Activities:

Dates/Special Position:

_____________________________________________________________________________________________

Dates/Award/Honors:

I hereby certify that the information I have supplied in this application form and supporting documents are true and correct to the best of my knowledge:

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Name (Print) Signature Date

Student name: _______________________________________________________________

Student Recommendation Form

1. I have known the applicant for a period of _____________________ in the following capacity:

2. Student Grade Point Average: _________

3. Please evaluate the applicant on the following traits:No Basis

Excellent 5

Good 4

Average 3

Fair 2

Poor 1 Comments

Communication Skills

Leadership Ability

Attendance / Punctuality

Quality of Work

Time Management

Organizational Skills

Writing Skills

Initiative

Professional Conduct

Self-Confidence

Maturity / Judgement

Creativity

Additional characteristics and considerations: (Please use other side if needed)

I recommend this student: with reservation fairly strongly strongly enthusiastically

Name of recommender: ________________________________________________________________________ (Please print)Title: _________________________________________________ Phone: _______________________________

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School: _____________________________________________________________________________________

Email: ______________________________________________________ Date: ___________________________

Signature, verifying GPA and above information: _________________________________________________

Student name: _______________________________________________________________

Student Recommendation Form

1. I have known the applicant for a period of _____________________ in the following capacity:

2. Student Grade Point Average: _________

3. Please evaluate the applicant on the following traits:No Basis

Excellent 5

Good 4

Average 3

Fair 2

Poor 1 Comments

Communication Skills

Leadership Ability

Attendance / Punctuality

Quality of Work

Time Management

Organizational Skills

Writing Skills

Initiative

Professional Conduct

Self-Confidence

Maturity / Judgment

Creativity

Additional characteristics and considerations: (Please use other side if needed)

I recommend this student: with reservation fairly strongly strongly enthusiastically

Name of recommender: ________________________________________________________________________ (Please print)Title: _________________________________________________ Phone: _______________________________

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School: _____________________________________________________________________________________

Email: ______________________________________________________ Date: ___________________________

Signature, verifying GPA and above information: __________________________________________________

THIS PAGE IS FOR YOUR REFERENCE ONLY – DO NOT SUBMIT

Please verify that you have enclosed all the items listed below. Incomplete applications will not be considered.

Minimum weighted grade point average of 3.0

Submit original application packet along with one (1) copy

Official high school transcript that includes weighted GPA/class rank

Two Student Recommendation Forms (sealed) enclosed with completed application packet

Please provide a recent wallet size photo

Resume listing your work and/or community service activities

NOTE: As a condition of participation, Students are required to have the following Immunizations and tests:

a tetanus booster within the past ten (10) years; a measles vaccination (if Participant was born after 1957); a rubella immunization (unless Participant provides serologic confirmation of immunity); a mumps immunization (unless Participant provides serologic confirmation of immunity); an intradermal, protein-derivative-type tuberculin skin test within the past twelve (12) months (unless Participant is known to have an allergic or positive reaction to same, in which case a chest X-ray is required); a Hepatitis B vaccination series (unless Participant signs an appropriate declination form); a varicella immunization (unless Participant provides serologic confirmation of immunity); and influenza vaccination(s).

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Requirements Checklist

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Prior to commencing the Project PROMISE clinical experience, students must complete and submit a urine drug screen (minimum drug screening requirements include testing completed at a CAP or SAMSHA certified lab using a nine (9) panel test including marijuana, cocaine, methamphetamines, benzodiazepines, PCPphencyclidine, opiates, methadone, arbiturates, and propoxyphene.)

Questions? Contact

Bryan McClure, Program DirectorPhone: 828-767-0066Email: Bryan.McClure@mahec.net

Misty Cox, Program Co-DirectorPhone: 828-771-3481Email: misty.cox@mahec.net

Rivers Woodward, Program Co-Founder

Brittany Papworth, Program Co-Founder

Revised: 2023-05-25

Deliver completed application packet and one additional copy to your guidance counselor, CTE director, or health science

teacher.

The application packet and recommendations must be received on or before November 11th, 2016.

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