Find Your Future Virtual Camp | UAMS Regional Campuses

Today's Date(Required)

Student Information

Name(Required)

First Middle Last

Date of Birth(Required)

Last 4 of Social Security Number

Academic/School Email(Required)

Preferred email for contact for this program

Alternate/Personal Email

Post-program email

Primary Phone Number(Required)

Secondary Phone Number

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

County(Required)

Permanent Address(Required)

If you live in an apartment please include Apt #

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your Mailing Address the Same as your Permanent Address?(Required)

Yes

Mailing Address(Required)

If you live in an apartment please include Apt #

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your hometown the same as your permanent address?(Required)

Yes

Hometown Address(Required)

City State / Province / Region ZIP / Postal Code Country

Gender(Required)

Ethnicity(Required)

1. Hispanic or LatinX: a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Race(Required)

1. American Indian/Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. 2. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand, and Vietnam. 3. Black or African American: A person having origins in any of the black racial groups of Africa. 4. Native Hawaiian/Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Marshall Islands or other Pacific Islands 5. White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Veteran Status(Required)

What is your background?(Required)

Do any of the following descriptions apply to you?(Required)

Please choose all that apply.

Person who is first generation to attend college

Person from high school with low SAT/ACT scores or below the average state test results

Person from a school district where 50% or less of graduates go to college

Person who has a diagnosed physical/mental impairment that substantially limits participation in education experiences

Person for whom English is not his or her primary language and for whom language is still a barrier to academic performance

Person from a family having an annual income that does not exceed 200% of poverty guidelines

None of the above

Camp Info

T-Shirt Size(Required)

A camp T-shirt will be included in your kit!

Education Information

Current High School(Required)

Current grade 2022-2023 school year:(Required)

GPA(Required)

Please put your current GPA in the field below

Transcript (Optional)

Please upload a copy of your most recent transcript. This is available from your school counselor.

Max. file size: 15 MB.

Legal

Confirm Access(Required)

This camp requires that all attendees are able to provide their own internet access and device (computer, Chromebook, etc.). By clicking “yes” below you are confirming that you have access to both internet and device during all days of your selected camp.

Yes

Summer Program Release(Required)

Please upload your signed copy of your Summer Program Release (form provided on our website).

Accepted file types: jpg, png, pdf, gif, Max. file size: 15 MB.

Confidentiality Agreement(Required)

Please upload the signed Confidentiality Agreement (form available on our website).

Accepted file types: jpg, gif, png, pdf, Max. file size: 15 MB.

This field is for validation purposes and should be left unchanged.

FIND YOUR FUTURE IN HEALTH CARE 2023

Student Information

Camp Info

Education Information

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