West Hills High School by HC121003211149

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									                 Fall 2012 Kaiser (Permanente) Internship Program (KIP)
                                Student Application Form

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, September 25, 2012.

*Required fields

*Date:

*First Name:                                       *Last Name:

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

*Spring 2012 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.

* What time does your school day end?

*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)

*Names of the adult(s) with whom you reside:

Adult 1: First Name:                                        Last Name:

Adult 2: First Name:                                        Last Name:
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                           Questions may be directed to your Health Pathway Coordinator
                          or Sonia Lira, HASPI Industry & College Connections Coordinator,
                                     at (619) 660-4280 or sonia.lira@gcccd.edu.

                       Visit us at www.HASPI.org and www.facebook.com/SD.HASPI
*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:

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

Previously Taken      Have Not Taken                     Name of teacher:

*Which healthcare internships/volunteer opportunities have you previously completed?
(Check all that apply)

  GUHSD Health-Careers Exploration Summer Institute (HESI)
  GUHSD Medic Internship Program
  Kaiser (Permanente) Internship Program (KIP)
  Scripps’ High School Exploration Program (HSEP)
  Scripps Chula Vista - San Diego Border Area Health Education Center (AHEC)
  SUHSD Sharp Chula Vista Internship
  UCSD Medical Center (Hillcrest) Internship
  Other (specify):
  Other (specify):
  Other (specify):




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                       Questions may be directed to your Health Pathway Coordinator
                      or Sonia Lira, HASPI Industry & College Connections Coordinator,
                                 at (619) 660-4280 or sonia.lira@gcccd.edu.

                     Visit us at www.HASPI.org and www.facebook.com/SD.HASPI
*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?




*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 the Kaiser
Permanente Internship Program. Proper grammar and spelling will affect your final score.
Provide a lot of detail and be sure to double-check your work for errors.




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

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

								
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