MEDICAL SCIENCE APPLICATION—Guilford High School
The Medical Science program is an off-campus program where students must provide their own reliable transportation to the class/work-site and then
back to school. Students will need to provide their own uniform. This course is designed for juniors and/or seniors interested in a health care career.
The student spends 2 hours per day, five days a week, at Rockford Health System, learning a core of knowledge and skills needed for many health
care fields. Students will have the opportunity to shadow various health care professionals such as physical therapists, nurses, and x-ray technicians.
Students will have the opportunity to obtain Illinois Nurse Assistant Certification. In addition, safety assessment (temperature, pulse, respiration and
blood pressure), patient transport, personal care techniques and other general health care skills are addressed. Students must have a B average in core
academic classes. Students will not receive an interview if their GPA is below a 2.5 cumulative. Students accepted typically have above a 3.0 GPA
and have an excellent attendance record. Students accepted to the program will not be allowed to drop as the seats cannot be filled at a later date.
Name ______________________________________________ Academy _______________________
Age ________ Current Grade Level _________
Counselor ___________________________________
Parent/Guardian Name _________________________________________________________________
Address ________________________________________ Phone Number _______________________
Do you have your own transportation for the 2016-2017 school year?
Yes _____ No _____
Please respond to these questions in complete sentences (paragraph form).
1. What assets will you bring to the class? (Be specific)
2. Why do you want to take this class?
3. What are your future plans in relationship to health careers?
Your counselor will attach your high school transcript and attendance record to this application for consideration.
Counselor Signature ________________________________________________________
Return this completed application to Mrs. Pauley in Room 234 by Wednesday, January 13, 2016.
TEACHER RECOMMENDATION FOR MEDICAL SCIENCE PROGRAM
Directions for the Student:
Please fill out the top half of this form and give one to EACH of your current core teachers (English, Math, and
Science). Each sheet has been labeled for one of the core subjects.
Student Name: __________________________________________________
School: _________GUILFORD HIGH SCHOOL___________________________
Counselor: ______________________________________________________
Subject: ______________ENGLISH __________________________________
Teacher ________________________________________________________
Directions for the Teacher:
Please mark the appropriate box and return the completed form to Mrs. Pauley in Room 234 by Wednesday,
January 14th. All forms collected by the counselor will be placed with the student’s application and forwarded
to Rosemary Papke (Medical Science instructor). Thank you for your cooperation.
Below Average
Average
Above Average
Excellent
Academic
Motivation
Concern for
Others
Emotional
Maturity
Reaction to
Setbacks
Comments:
_________________________________________________
Teacher Signature
______________________
Date
Please return to Mrs. Pauley in Room 234 by Wednesday, January 13, 2016.
TEACHER RECOMMENDATION FOR MEDICAL SCIENCE PROGRAM
Directions for the Student:
Please fill out the top half of this form and give one to EACH of your current core teachers (English, Math, and
Science). Each sheet has been labeled for one of the core subjects.
Student Name: __________________________________________________
School: _________GUILFORD HIGH SCHOOL___________________________
Counselor: ______________________________________________________
Subject: ______________MATH__ __________________________________
Teacher ________________________________________________________
Directions for the Teacher:
Please mark the appropriate box and return the completed form to Mrs. Pauley in Room 234 by Wednesday,
January 14th. All forms collected by the counselor will be placed with the student’s application and forwarded
to Rosemary Papke (Medical Science instructor). Thank you for your cooperation.
Below Average
Average
Above Average
Excellent
Academic
Motivation
Concern for
Others
Emotional
Maturity
Reaction to
Setbacks
Comments:
_________________________________________________
Teacher Signature
______________________
Date
Please return to Mrs. Pauley in Room 234 by Wednesday, January 13, 2016.
TEACHER RECOMMENDATION FOR MEDICAL SCIENCE PROGRAM
Directions for the Student:
Please fill out the top half of this form and give one to EACH of your current core teachers (English, Math, and
Science). Each sheet has been labeled for one of the core subjects.
Student Name: __________________________________________________
School: _________GUILFORD HIGH SCHOOL___________________________
Counselor: ______________________________________________________
Subject: ______________SCIENCE __________________________________
Teacher ________________________________________________________
Directions for the Teacher:
Please mark the appropriate box and return the completed form to Mrs. Pauley in Room 234 by Wednesday,
January 14th. All forms collected by the counselor will be placed with the student’s application and forwarded
to Rosemary Papke (Medical Science instructor). Thank you for your cooperation.
Below Average
Average
Above Average
Excellent
Academic
Motivation
Concern for
Others
Emotional
Maturity
Reaction to
Setbacks
Comments:
_________________________________________________
Teacher Signature
______________________
Date
Please return to Mrs. Pauley in Room 234 by Wednesday, January 13, 2016.