HEAL (San Leandro) School Year

Cohort

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Personal Information

First Name*

Last Name*

Nickname

Date of Birth*

Gender*

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Race/Ethnicity*

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Race/Ethnicity Specified

Primary Language*

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Primary Language (if not listed)

Email*

Alternate Email

Phone Number*

Enter YOUR number

Phone

Street Address*

Street Address Line 2

City*

State*

California

Postal / Zip Code*

Parent/Guardian Information

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent/Guardian Phone Number*

Phone

Parent/Guardian Email

Primary language spoken by parent/guardian*

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Name of primary language(s) not listed

How many people live in your household?*

Educational Background

School*

San Leandro High School

Grade/ Education Level*

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Student ID*

Name of Health Pathway or Academy*

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Name of internship teacher, pathway teacher, advisor, or staff person providing support in application process

Have you ever applied to the HEAL Program (prior to this application)?*

Yes

Have you previously participated in an internship?*

Yes

I don't know

Are you, or would you, be the FIRST in your family to...*

Graduate from High School

Attend College

Graduate from College

None of these apply

Do you qualify for free/reduced school lunch?*

Yes

Health Career Interest

Which health job/career(s) are you interested in?

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If "Other" selected, specify what job/career you're interested in

Community Involvement - Health Related Programs

Have you been involved with any of the following health related programs?

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List other community organizations you have been involved with

Agreement

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted, any false statements, omissions, or other mis-representations made by me on this application may result in my immediate dismissal.

I agree*

Send me a copy of my responses

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