M*A*S*H | Mini M*A*S*H | CHAMPS Arkansas Statewide Application MASH Application for students across Arkansas Step 1 of 4 25% Personal Information and DemographicsName(Required) First Middle Last Alternative name:If you go by a name other than your legal name, you may enter it here: Student Cell Phone Number(Required)Personal Email(Required)This will be the email used to contact you. It should be an email you will have access to throughout the year. Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) MM slash DD slash YYYY Last 4 Digits of Social Security Number(Required) Gender(Required)MaleFemaleOtherPrefer Not To SayEthnicity(Required)Hispanic/LatinoNon-Hispanic/LatinoRace(Required)American Indian or Alaskan NativeAsianBlack or African AmericanWhite or CaucasianNative Hawaiian or Pacific IslanderMore than one race (please specify)If "More Than One" race was selected, please specify: Are you from a disadvantaged background?(Required)Select "YES" if ANY of the following apply · 1st Generation to attend college · From high school with low SAT/ACT Scores or below the average state test results (School’s numbers) · From school district where 50% or less of graduates go to college · Diagnosed physical/mental impairment that substantially limits participation in education experiences · English is not primary language and language is still a barrier to academic performance YesNoUnsureParent/Guardian InformationParent/guardian will be required to sign student release forms. Information below is for parent/guardian contact purposes. Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Parent Cell Phone Number(Required)Is parent/guardian address same as applicant address?(Required)YesNoAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is this parent/guardian the emergency contact?(Required)YesNoEmergency Contact Name(Required) First Last Emergency Contact Cell Phone(Required) Camp InformationCamp Location and Dates(Required)Students may only apply for one camp. Please select camp based on county of residence. If unsure which camp to select, please refer to the guide at regionalcampuses.uams.edu/mash-2023/CHAMPS UAMS Fayetteville June 14-16CHAMPS Ashley County Medical Center June 5-9MASH Arkansas Methodist Medical Center June 5-16MASH Ashley County Medical Center June 5-16MASH Baptist Health Fort Smith July 3-14MASH Baptist Health Hot Springs County July 17-28MASH Bradley County Medical Center June 19-30MASH Drew Memorial Health System June 12-23MASH Fayetteville June 12-23MASH Harrison North Arkansas Regional Medical Center June 12-23MASH Mercy Hospital Fort Smith June 19-30MASH Mercy Medical Center Rogers June 19-30MASH UAMS Pine Bluff June 19-30MASH UAMS Texarkana June 12-23Mini MASH Blytheville June 19-23Mini MASH Chicot Memorial Lake Village June 5-9Mini MASH Conway Regional Medical Center June 19-23Mini MASH Crittenden County June 26-29Mini MASH DeWitt Hospital July 24 - Aug 2Mini MASH El Dorado June 12-16Mini MASH Forrest City June 5-9Mini MASH Helena West Helena June 12-16T-Shirt Size(Required)SmallMediumLargeExtra Large2XLDietary RestrictionsFood may be served during camp. Please list any food allergies or dietary restrictions below. Medical ConditionsIf you have any medical conditions we should be aware of, please list below - this includes allergies, pregnancy, diabetes, epilepsy, etc. *Please note: For your safety, we ask that you tell us about any medical conditions. Information is private and will not disqualify you from the program. Education Information & Career GoalsName of High School(Required) Current GPA(Required)This will be verified with current transcript. Current Grade Level(Required)Current grade level is the grade you are in when applying for MASH (Spring 2023). Students who are applying for M*A*S*H or Mini M*A*S*H must be currently enrolled in 10th or higher grade level. 8th (CHAMPS ONLY)9th (CHAMPS ONLY)10th11th12thVerification of Science Courses (M*A*S*H/Mini M*A*S*H Only) I am currently enrolled in or have completed at least one Biology class at my high school, which will be confirmed on my transcript.What health career are you MOST interested in?(Required) Significant School Activities(Required)Please list your significant SCHOOL activities, achievements, and awards of the past three years. You may add additional rows as needed. Add RemoveOther Significant Activities(Required)Please list your significant NON-SCHOOL (community, church, etc.) acheivements of the past three years. You may also describe any jobs or duties you have that describe your level of committment to a task. You may add additional rows as needed. Add RemoveStudent Essay(Required)Please write in your own words why you are interested in attending M*A*S*H and why you want to learn about health careers. Your response to this question is very important in the selection process. Disciplinary PolicyDisciplinary Policy Consent(Required)M*A*S*H faculty and staff aim to maintain a safe, positive, and educational environment for all participants. Certain behaviors can result in your immediate dismissal from the M*A*S*H program and notification of your parent/guardian. These behaviors include, but are not limited to: - Deliberate violation of UAMS's or host facility's safety rules or policies - Possession of alcohol and/or illegal drugs - Being intoxicated or under the influence of any controlled substances - Use of tobacco products during program hours - Violation of dress code or cell phone policy - Inappropriate language or discussions - Violation of HIPAA rules and regulations - Harmful or inappropriate contact or communication with other participants or staff - Deliberate destruction or damage to property - Unexcused tardiness or absence I agree that I will abide by the UAMS M*A*S*H/Mini M*A*S*H/CHAMPS Disciplinary Policy as outlined in the document.Attendance PolicyTransportation(Required)I understand that this camp is a day camp and I am required to my own provide transportation to the camp each day. I agree to provide tansportation to and from M*A*S*H.Attendance(Required)Student attendance is required for the entire camp. Students who have a family emergency must contact their camp director immediately. I agree to the attendance policyForms and ReleasesPlease see the list of needed documents that will be submitted as part of the online application. There may be additional forms if accepted to camps. School Recommendation Forms(Required)Upload your Counsleor Academic Endorsement Form and Teacher/School Recommendation forms (varies by camp) here. Drop files here or Select files Accepted file types: jpg, png, pdf, docx, Max. file size: 15 MB. Transcript(Required)Please upload a copy of your school transcript here. This can be obtained from your school counselor. Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 15 MB. Photo Release(Required)Please upload your signed photo release. If you are unable to be photographed for any reason (ie foster care, legal) please upload your document with a written note. Drop files here or Select files Accepted file types: jpg, gif, pdf, docx, png, Max. file size: 15 MB. Parent Consent(Required)Please upload your Parent Consent Form here. Drop files here or Select files Accepted file types: jpg, pdf, png, docx, Max. file size: 15 MB. Confidentiality and Hold Harmless Agreement(Required)Please upload your Confidentiality and Hold Harmless Agreement here. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 15 MB. Additional Forms and Waivers(Required) I acknowledge that some M*A*S*H Camp locations have additional forms and waivers for associated organizations that will be required for participation.Additional FormsStudents may upload any additional documentation requested by Camp Directors. Drop files here or Select files Accepted file types: pdf, gif, png, docx, jpg, Max. file size: 15 MB. COVID-19 Policies(Required)Each orgainziation has rules and regulations for the safety of students participating in M*A*S*H Camps and activities regarding COVID-19. You will be notified what the requirements for your camp are by email. Requirements will differ by organization, but may include requirements for proof of vaccination, approved religious or medical exemption, or use of mask while on campus or in patient areas. If you have any questions you may contact your camp director after completion of the online portion of the application. I acknowledge that if I am accepted I may be required to show proof of vaccination for COVID-19 or apply for exemption. I may be asked to wear a mask while on campus or in patient areas.Application for Acceptance(Required) I understand that by completing this application I am applying for a M*A*S*H/Mini M*A*S*H/CHAMPS Camp. Completed this application DOES NOT guarantee acceptance.
