BACKGROUND ☐ ☐ Have you been exposed to careers in health care? Yes No If yes, how? What are Mother or Father or your parents’/legal guardians’ educational background? Place an or checkbox besides the most applicable response. Parent/Guardian 1 Parent/Guardian 2 “X” Did not complete high school Graduated from high school or attained G.E.D. Completed some college or Training/Certificate Program Associate’s Degree Degree Bachelor’s or Professional Degree (MBA, MS, MD, PhD, etc.) MASTER’S, Graduate Unknown (before taxes from all sources) What is the best estimate of your family’s household income? ☐ $20,000 - $35,000 ☐ $35,000 - $50,000 ☐ $50,000 - $65,000 ☐ $65,000 - $80,000 ☐ ☐ $80,000 - $95,000 $95,000 & higher How many people live within your household? ☐ 1-2 ☐ 3-4 ☐ 5-7 ☐ 8 OR MORE INTERNSHIP INFORMATION Some internship departments are seeking interns who have different levels of experience with different computer software. Previous experience with these activities is not a requirement to participate in the program. Please indicate with an if you have completed the following types of projects in the past: NO YES ‘X’ Created a Powerpoint or other computer-based presentation Completed a verbal presentation in front of 5 or more people Entered data into an Excel spreadsheet or other database software Calculated data while using Excel or other database software Used Microsoft Access to enter or retrieve information Rank the following healthcare careers that interest you the most, labeling 1 as most preferred, and 4 as least preferred. If you are unsure, you may leave this section blank. _____ Administration & Support Services _____ Human Resources _____ Information Technology _____ Clinical Positions
BACKGROUND Have you been exposed to careers in health care? ☐ Yes ☐ No If yes, how? What are your parents’/legal guardians’ educational background? Place an “X” or checkbox besides the most applicable response. Mother or Parent/Guardian 1 Father or Parent/Guardian 2 Did not complete high school Graduated from high school or attained G.E.D. Completed some college Associate’s Degree or Training/Certificate Program Bachelor’s Degree MASTER’S, Graduate or Professional Degree (MBA, MS, MD, PhD, etc.) Unknown What is the best estimate of your family’s household income? (before taxes from all sources) ☐ $20,000 - $35,000 ☐ $35,000 - $50,000 ☐ $50,000 - $65,000 ☐ $65,000 - $80,000 ☐ $80,000 - $95,000 ☐ $95,000 & higher How many people live within your household? ☐ 1-2 ☐ 3-4 ☐ 5-7 ☐ 8 OR MORE INTERNSHIP INFORMATION Some internship departments are seeking interns who have different levels of experience with different computer software. Previous experience with these activities is not a requirement to participate in the program. Please indicate with an ‘X’ if you have completed the following types of projects in the past: NO YES Created a Powerpoint or other computer-based presentation Completed a verbal presentation in front of 5 or more people Entered data into an Excel spreadsheet or other database software Calculated data while using Excel or other database software Used Microsoft Access to enter or retrieve information Rank the following healthcare careers that interest you the most, labeling 1 as most preferred, and 4 as least preferred. If you are unsure, you may leave this section blank. _____ Administration & Support Services _____ Human Resources _____ Information Technology _____ Clinical Positions