Wake Tech Health Sciences Campus
October 12 - October 16, 2015
9:00 AM – 4:00 PM
2901 Holston Lane
Raleigh, NC 27610
EMAIL ADDRESS:
[Please print clearly. This email address will be used to send confirmation and future Health Careers information.]
First Name
Nickname
MI
Last Name
Suffix
Social Security # [Last 4 Digits Only]
CAMP DESCRIPTION:
Track out of school and into Health Careers! Students will participate in a five-day health career
exploration sponsored by Wake AHEC and Wake Tech Community College at the Wake Tech Perry Health
Sciences Campus. Students will meet various health professionals and learn about careers as they tour
multiple departments and participate in educational activities. We will cover topics such as: Emergency
Services, Radiography, Medical Assisting, Dental Hygiene, Nursing, and Surgical Technology.
The schedule is 9:00 AM to 4:00 PM, Monday through Friday. Drop-off is between 8:30 AM and 9:00 AM.
Confirmed times and an agenda will be distributed prior to the program.
RACE:
___American Indian/Alaska Native
___B l a c k / A f r i c a n - A m e r i c a n
ETHNICITY (PLEASE CHECK ONE):
___Hispanic
___Non-Hispanic
___W h i t e / C a u c a s i a n
___N a t i v e H a w a i i a n / P a c i f i c I s l a n d e r
___A s i a n [ s p e c i f y ] :
TO REGISTER:
___M o r e t h a n o n e r a c e
GENDER:
___M a l e
___F e m a l e
ONLINE:
www.wakeahec.org/hchome.htm
Birthdate:
/
FAX: [919] 350-0470
/
MAIL:
Wake AHEC Health Careers
3261 Atlantic Avenue, Suite 212
Raleigh, NC 27604
Name of School
ORIENTATION:
Both student and parent(s) will be required to
attend a mandatory orientation session on the
first morning before camp Monday,
October 12, 2015 at 8:30am to obtain
additional information and camp rules.
COST:
The fee of $150.00 per student includes supplies,
lunch, and snacks. Options for payment include
check or credit card. Payment plans may be
arranged on an individual basis. Reservations will
not be held or processed without full or down
payment of the registration fee.
Current Grade
Expected Graduation Year
Health Career Interest
HCSETS #: 4725
Please list specific field
[For example: pediatrics, surgeon]
Do you require special accommodations [for a disability]?
___Y e s
___N o
If Yes, briefly describe:
P.O. Box or Street Address
CANCELLATION:
Refunds will only be issued for cancellations made by September 28, 2015. No partial refunds will be
issued.
REGISTRATION
Online Registration: www.wakeahec.org/hchome.htm
1. Fax: (919) 350-0470
2. Wake AHEC Health Careers
ATTN: Heather Schafer
3261 Atlantic Avenue, Ste 212
Raleigh, NC 27604
Please register online or complete the
registration form and return it by Friday, October 2, 2015
Questions: Contact Heather Schafer at hschafer@wakeahec.org or (919) 350-0468.
City
State
Parent’s/Guardian’s Name
Parent’s/Guardian’s Name
Home County
]
[
Home Phone
Relationship
[
]
Cell Phone
Email Address
Relationship
[
]
Cell Phone
Email Address
Zip
Payment Options: ___ Check enclosed for $150.00 [Make check payable to Wake AHEC Health Careers.]
___ Payment Plan: $50.00 must accompany the registration form
Full payment is due by October 9, 2015.
___ Payment of $150.00 by credit card: (MasterCard, Visa, American Express, Discover)
Card #
Authorized Signature
Card Code
Expiration Date
Print Name as it Appears on Card