Health Career Camp Enrollment Form

Deadline to Submit Enrollment Form: June 30, 2025

Camp Date/Time:

July 31, 2025

8:30 am – 4:30 pm

Location: New Horizons Healthcare, 3716 Melrose Ave NW, Roanoke, VA 24017

If you have questions regarding this application, please call us at (540)224-5355

Date Completed

mm/dd/yyyy

Applicant First Name

Applicant Last Name

Applicant Preferred Name

Applicant Date of Birth

mm/dd/yyyy

Applicant Email

Mailing Address

City

State

Zip Code

Name of School

Grade Entering This Fall

Race

Gender

Pronouns

Applicant's First Language

Applicant's Second Language

Write "none" if there is not a second language.

Interpreter Needed?

What health careers are you interested in?

You can select more than one option.

Applicant Feedback Section 1

Please share any specific experiences or events that sparked your passion for science, health, and/or wellness.

Applicant Feedback Section 2

If you could invent a tool or program to improve people's health, what would it be and how would it help?

The questions below to be completed by a parent/guardian

Any Food Restrictions or Allergies?

Does the applicant have any food restrictions or allergies that the camp staff should be aware of?

If yes, please describe:

Any significant health history?

Does the applicant have any significant health history (e.g., heart condition, diabetes, any injury), or health restrictions that the camp staff should be aware of?

If yes, please describe

Does your child take any medications?

If yes, please list:

Parent/Guardian Name(s)

Parent/Guardian Phone Number(s)

Parent/Guardian Email(s)

What is the best way to contact parent/guardian?

Will the participant need transportation?

Preferred Pick-Up/Drop-Off Location

Please specify your preferred pick-up/ drop-off location if it differs from the address listed in your application

Are you interested in learning more about FAFSA?

The FAFSA is the Free Application for Federal Student Aid. Students submit the FAFSA to apply for financial aid for college from the federal government, state governments and most colleges and universities. All undergraduate students and graduate students should file the FAFSA, even if they think they won’t qualify for financial aid. The FAFSA determines a student’s eligibility for need-based aid, including work-study options and the Federal Pell Grant. But, the FAFSA also gives you access to federal parent and student loans, which offer lower interest rates and better repayment terms than a private loan.

If yes, you can join us during the camp lunch hour between 12:00pm and 1:00pm to hear a FAFSA presentation along with the participants.

Estimated Annual Household Income

Parent/Guardian Consent

By typing your name in the below box, you grant permission for:

Your child to participate in Carilion's Health Career Camp. Additionally, you are acknowledging that photos or videos may be taken during the camp for promotional purposes and consent to their use.
Your child to be transported by a contracted transportation service to and/or from camp (for participants requiring transportation), or to and from camp activities during the day. I understand that the mode of transportation may include buses, vans, or cars, and that the transportation may take place on public roads. I understand that the camp staff will take all necessary precautions to ensure the safety of my child during transportation.
Camp staff or appropriate medical personnel to provide first aid, emergency medical care, or if necessary, admission to an accredited hospital, when such care is necessary for the treatment of any injuries my child may sustain while participating in camp activities. I understand that I will be notified as soon as possible if such an emergency occurs.

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