MASH Camp Application - Northern Area Health Education Center, Inc.

Camp Information

Select the camp you want to attend*

The Canton-Potsdam Mash Camp 2019 is sponsored by

MASH Camp Scholarship Application Form: Click Here

Applicant Information

First Name*

Middle Inital

Last Name*

Date of Birth*

Address*

Street Address City State Zip

Email*

Contact Number*

Scrub Size*

Please list any food allergies here or indicate NONE.*

Does the applicant have parent or family member who is an employee of the camp location?*

Yes
No

Has the applicant attended MASH camp previously?*

Yes
No

Participant Essay

In 500 words please explain why you would like to attend this program.*

Demographics

Ethnicity*

Are you Hispanic or Latino

Yes
No

Race*

Check all that apply:

American Indian or Alaskan Native
Asian: underrepresented (i.e., Cambodia, Malaysia, Pakistan, Vietnam)
Asian: Non-underrepresented (i.e., China, Philippine, Japan, Korea, India, Thailand)
Black or African American
Native Hawaiian or Other Pacific Islander
White – Non Disadvantaged* (see below)
White – Disadvantaged* (see below)

Sex*

Background Information

Education Level*

Name of School District Attended*

State of School District*

Educationally Disadvantaged

An individual who comes from an environment that has hindered the individual in obtaining the knowledge, skills and abilities required to enroll in and graduate from a health professions school. The following are provided as examples of "Educationally Disadvantaged" for guidance only and are not intended to be all-inclusive.
Examples:
1. Person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences.
2. Person for whom English is not their primary language and for whom language is still a barrier to their academic performance.
3. Person who is first generation to attend college and who is from a rural or urban area or receiving public assistance.

Are you from an educationally disadvantaged background (according to the federal definition above)?*

Yes
No

Economically Disadvantaged

An individual who comes from a family with an annual income below a level based on low-income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary for use in all health professions programs. The Secretary will annually publish these income levels in the Federal Register. The table below provides a breakdown of family income levels used to determine economic disadvantaged status. Family income is defined as the income of the trainee's parents regardless of the age of the trainee.

Size of Family Unit* - - Low-Income Levels**

1 - - $21,660
2 - - $29,140
3 - - $36,620
4 - - $44,100
5 - - $51,580
6 - - $59,060
7 - - $66,540
8 - - $74,020

* Includes only dependents listed on Federal income tax forms.
** Income Level Adjusted gross income for calendar year

Are you from an economically disadvantaged background (according to the federal definition above)?*

Yes
No

Media Release

Media Release Confirmation*

Yes
No

I hereby authorize the Northern Area Health Education Center (NAHEC) and hosting facility to photograph, videotape and/or interview or permit others to photograph, videotape and/or interview me or my child. Photos, video clips, and/or interview content of me or my child can be used in media releases (print, radio, internet, or television) or on the NAHEC or hosting facility's website, Facebook page, display boards, brochures, newsletters and other promotional/educational materials in support of the NAHEC mission.

Confidentiality Acknowledgement

Confidentiality Acknowledgement Confirmation*

I understand that in the course of my experience at the camp location, I may learn things of a confidential nature. I agree to keep all information heard directly or indirectly concerning a patient or hospital personnel confidential. I also agree not to disclose information concerning a patient, nor offer patients or family’s advice or opinions. I will respect all patients’ rights.

I Agree

Parent Information

Please complete if applicant is under 18 years of age.

First Name

Last Name

Email

Enter Email Confirm Email

Contact Number

Relationship to Applicant

Payment

If you are accepted into the MASH Camp, you will be sent payment instructions.

Camp Fee

Price:

mash camp registration

Camp Registration