EMS Education Day - Northern Area Health Education Center, Inc.

Name*

First Last

Date of Birth*

Address*

Street Address City ZIP / Postal Code

Email*

Phone*

Sex*

Education Level*

Name of School District*

T-shirt size*

List any food allergies or indicate NONE*

Participant Essay*

In 200 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)

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

Confirmations

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 Confirmation*

I Agree

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.

Parent Information

Name*

First Last

Relationship to Applicant*

Email

Phone

Payment

If you are accepted into this Event, you will be sent payment instructions.

Event Fee

$25.00

EMS Education Day Registration