West Hills High School

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					                           Student Internship Application Form
                                      Summer 2012


Instructions: Application must be typed. Email completed application as a Microsoft Word
document to Sonia Lira at sonia.lira@gcccd.edu by 5 p.m. on Tuesday, April 3, 2012.

*Required fields

*Date:

*First Name:                                   *Last Name:

*High School Name:                             *Current Grade: 10th                   11th     12th

*Fall 2011 Semester Grade Point Average (GPA):                            *Current GPA:
If you do not have a 2.5 GPA or greater for both semesters, do not proceed with completing
this application.

*Are you 16 years or older?: Yes          No        *Are you 18 years or older?: Yes                   No

*Address:                                                        *City:

State: CA    *Zip Code:                *Email Address:

*Home phone number:                    Check here if you do not have a home phone:

*Cell phone number:                    Check here if you do not have a cell phone:

*Adult(s) with whom you reside: Parent(s)                Guardian(s)                Self/Emancipated

 Other Family Member(s) - Specify the relationship:

 Friend(s)




                                         Questions may be directed to                                       1 of 4
                           Sonia Lira, Industry & College Connections Coordinator
                                  (619) 660-4280 or sonia.lira@gcccd.edu

                                             Visit us at
                                          www.HASPI.org
                                     www.facebook.com/SD.HASPI
*Names of the adult(s) with whom you reside:

Adult 1: First Name:                                         Last Name:

Adult 2: First Name:                                         Last Name:

* Which area of medicine are you interested in?:

*Which Health Career Pathway courses have you taken? (Check all that apply)

Medical Biology: Currently Enrolled                    Previously Taken                   Have Not Taken

Name of teacher:

Medical Chemistry or Biochemistry: Currently Enrolled                                   Previously Taken

Have Not Taken             Name of teacher:

Physiology/Anatomy: Currently Enrolled                        Previously Taken                Have Not Taken

Name of teacher:

Other Health Pathway Class           (specify class name):                                  Currently Enrolled

Previously Taken           Have Not Taken                    Name of teacher:

Other Health Pathway Class           (specify class name):                                  Currently Enrolled

Previously Taken            Have Not Taken                   Name of teacher:

*For which internship program(s) would you like to be considered? (Please reference the
distance and requirements for each program before checking)

  Health-Careers Exploration Summer Institute (HESI): GUHSD Health Career Pathway
students ONLY)

Scripps’ High School Exploration Program (HSEP): Choose two sites max.
       Mercy Hospital Chula Vista
       Mercy Hospital Hillcrest (north of Downtown San Diego)
       Green Hospital (Torrey Pines, near UCSD)
       Memorial Hospital La Jolla (near UCSD)
       Encinitas Hospital
       Clinic - Torrey Pines (near UCSD)


                                             Questions may be directed to                                  2 of 4
                               Sonia Lira, Industry & College Connections Coordinator
                                      (619) 660-4280 or sonia.lira@gcccd.edu

                                                 Visit us at
                                              www.HASPI.org
                                         www.facebook.com/SD.HASPI
*Which healthcare internships/volunteer opportunities have you previously completed?
(Check all that apply)

   Alvarado Hospital Internship Program
   GUHSD Health-Careers Exploration Summer Institute (HESI)
   GUHSD Medic Internship Program
   PPH Clinical Career Extenders
   Scripps’ High School Exploration Program (HSEP)
   SUHSD Camp Scripps (AHEC)
   SUHSD Sharp Chula Vista Internship
   UCSD Health Sciences’ Health Careers Opportunity Program (HCOP) & Research
      Methodology Training Lab (RMTL) Summer Internship
   UCSD Medical Center (Hillcrest) Internship
   Other (specify):
   Other (specify):
   Other (specify):

*Transportation Plan 1: How do you plan to get from home to your internship every day?




*Transportation Plan 2: In case Plan 1 fails, what is your backup transportation plan?




                                         Questions may be directed to                    3 of 4
                           Sonia Lira, Industry & College Connections Coordinator
                                  (619) 660-4280 or sonia.lira@gcccd.edu

                                             Visit us at
                                          www.HASPI.org
                                     www.facebook.com/SD.HASPI
*In the space below (DO NOT attach in a separate document), provide a one-page or less
(double-spaced) essay discussing your motivation for participating in a HASPI internship.
Proper grammar and spelling will affect your final score. Provide a lot of detail and be sure
to double-check your work for errors.




                                          Questions may be directed to                  4 of 4
                            Sonia Lira, Industry & College Connections Coordinator
                                   (619) 660-4280 or sonia.lira@gcccd.edu

                                              Visit us at
                                           www.HASPI.org
                                      www.facebook.com/SD.HASPI

				
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