We Treat You Like Family
DATE:
January 27, 2016
TO:
Counselor – Crossett Norman Junior High School
Counselor – Hamburg Junior High School
Counselor – Trinity
Parents of Junior High Students
FROM:
Shirley White/ Human Resources Director
SUBJECT:
2016 CHAMPS PROGRAM AT ACMC - June 13-17, 2016
The CHAMPS Program (Community Health Action I Medical Public Service) will be held
June 13-17, 2016 at Ashley County Medical Center. CHAMPS is a program for junior high students in rural South
Arkansas Communities that provides hands-on experiences in health careers, health education, and community service.
During the one-week program students work with local private medically related offices and businesses and with various
departments in the hospital itself by rotating through different activities each day and shadowing various health care
providers. Students in the program will be certified in CPR and Basic First Aid, make a First Aid Kit for personal use,
participate in a community service project, and learn the importance of healthy lifestyle habits.
The course will begin each morning at ACMC at 8:30a.m. and end around 4:00 p.m. Lunch will be served each day of the
program, and a graduation luncheon honoring the students will be held Friday with parents invited.
This program is offered at no charge to any 9 to 12 junior high students (Students from Crossett, Hamburg, Abiding Faith
and Trinity of current seventh, eighth and ninth graders) interested in health-related careers. The selection criteria are
based on the student’s scholastic ability as reported by transcripts, recommendations of counselor, science or health
teachers and the application prepared by the student.
You (Counselor) should submit the following items on each student to be considered for the CHAMPS program:





CHAMPS School Recommendation Forms – enclosed
CHAMPS Student Application Forms – Enclosed
CHAMPS Parental/Guardian Consent to participate
CHAMPS Photography Release Agreement
Student’s Scholastic Transcript – you provide
All information should be returned by April 20, 2016. Please send to the attention of Shirley White, Ashley County
Medical Center, P.O. Box 400, Crossett, AR 71635. If you need additional information, please feel free to call me at
(870) 364-1272. Additional applications at www.acmconline.org.
CHAMPS – Week of June 13-17
Ashley County Medical Center APPLICATION FORM
June 13– June 17, 2016
DEADLINE TO APPLY: April 20, 2016
Please print clearly
1st /
STUDENT:
2nd time to apply to CHAMPS (circle one)
1. Name:__________________________________________________________________________________
Last
2. M / F
First
Middle initial
Race:________________ Date of Birth: __________/__________/____________
Month
Day
Year
3. Do you go by a different name? If so, what is it? ______________________________________________
4. Hometown Address:______________________________________________________________________
Street or P.O. Box
___________________________________________________________________________________
City
State
Zipcode
5. Home phone number: ____________________ Cell phone number: _________________________
Area code/number
Area code/number
6. E-mail address ___________________________________________________(if you don’t have one, create one)
7. High School :________________________________________ Year you will graduate:______________
8. School Mailing Address:_________________________________________________________________
(Street or P.O. Box)
(Town)
9. Tee Shirt (circle one): S M L XL XXL
10. Food Restrictions – allergies _____________________________________________________________
________________________________________________________________________________________
PARENT or GUARDIAN:
11. Name: _________________________________________________________________________________
12. Home Address: ________________________________________________________________________
______________________________________________________________________________________
13. Home/Work phone number:______________________ Cell phone number: _____________________
Area code/number
Area code/number
14. List your significant SCHOOL activities, achievements and awards of the past two years:
(Please write neatly. Attach another sheet of paper if necessary.)
15. List your significant NON-SCHOOL (community, church, etc.) achievements of the past two years. Also
describe any jobs or duties you have at home or school that demonstrate your level of commitment to a task.
(Attach another sheet of paper if necessary).
16. Circle the response that best expresses your current opinion. Please be honest. This is purely to assess preprogram interest and will NOT be considered in the selection process.
Definitel
y
Probabl
y
Mayb
e
Probabl
y Not
Not at
all
1) How much do you intend, plan, or would like to
enter a HEALTH CAREER?
5
4
3
2
1
2) How much do you intend, plan, or would like to
work in PRIMARY CARE or in a primary care
setting? (For example as a family doctor, nurse
practitioner, or physician assistant in a Family
Medicine, General Internal Medicine, or General
Pediatrics clinic.)
5
4
3
2
1
3) How much do you intend, plan, or would like to
work with people who are MEDICALLY
UNDERSERVED? (These are people who face
financial, cultural or language barriers to health
care).
5
4
3
2
1
4) How much do you intend, plan, or would like to
work in a RURAL area (not a big city).
5
4
3
2
1
17. Please write in your own words why you are interested in attending CHAMPS – (Community Health Action in
Medical Public Service) and why you want to learn about health careers. Your response to this question is very
important in the selection process. If you need more room, attach another page to your application.
ACCEPTANCE STATEMENT
All your expenses for CHAMPS are being paid by the Statewide Mentor Partnership. On the last day of
CHAMPS, your community sponsor will be invited to attend a luncheon with you and the other participants. You
must agree to attend for the full length of the program (1 weeks). Please note that this is a day program and that
transportation to and from each daily session is your responsibility.
Signed:_______________________________________________ Date:_____________________
(Student)
PERMISSION STATEMENT
I hereby grant permission for my son/daughter to apply to this program and for school officials to report my
child's achievement and grades. I understand that if my son/daughter is accepted, we will be responsible for
his/her daily transportation for the two-week program.
Signed:______________________________________________ Date:______________________
(Parent/Guardian)
CHAMPS SCHOOL RECOMMENDATION FORM
(INFORMATION FROM SCHOOL PERSONNEL ON STUDENT APPLYING. CONFIDENTIALITY WILL BE HONORED.)
1. Student Name
____________
(first)
2. Gender:
(middle)
(last)
Race
3. School Name:
____________
School District
_____________
4. School Address
(Street or P.O. box)
*5. Attach a readable transcript of this
citizenship grades or comments or ACT scores.
(Town)
(Zip Code)
student's grades to this form.
_____________
(County)
Please include any
6. TEACHER: THIS INFORMATION IS CONFIDENTIAL. Please state why you think this student would
benefit from participating in CHAMPS. Comments should be made regarding the student's abilities and potential
for success in a health care environment. Use the space provided, then sign at the bottom of this page.
Teacher's signature*
Today's date
Printed Teacher Name ___________________________________________
Email _________________________________________________________
What Class do you Teach?________________________________________
(Continued on next page)
7. Include any additional information here from other faculty members that would assist the screening committee
in making their selections.
___________________________________________
Faculty Signature
__________________________________
Date
Printed Faculty Name______________________________________________________________
ACADEMIC ENDORSEMENT
We have discussed pertinent information on this form with this student and agree that he/she is genuinely
interested in participating in the CHAMPS program.
Counselor's signature*
Today's date
_______________________________________
Counselor’s Printed Name
_______________________________________
Counselor’s Email
* These signatures are required in order for the student to be considered by the selection committee.
Student’s Cumulative GPA ________________________________
PLEASE MAIL COMPLETED APPLICATION AND TRANSCRIPT (MUST INCLUDE CUMULATIVE
GRADE POINT AVERAGE) by April 20, 2016 TO:
CHAMPS PROGRAM
Shirley White
Ashley County Medical Center
P.O. Box 400
Crossett, AR 71635
or Return to Counselor at school and we will pick up.
Parental/Guardian(s) Consent for Participation in C*H*A*M*P*S
Name of Child: _______________________________ Date of Birth: ____________________
I understand that my child has been selected to participate in the Community Health
Action in Medical Public Service (C*H*A*M*P*S) Program at Ashley County
Medical Center and I hereby give my permission for my child to participate in this
program. It is your responsibility for daily transportation to and from the camp.
___________
Initial
I am aware that regular attendance at the C*H*A*M*P*S Program and adherence to
Ashley County Medical Center policies and procedures will be required of my child.
___________
Initial
I understand that it is my child’s responsibility to become familiar with all
orientation materials.
___________
Initial
I understand that my child will take a CPR course which may include physical
strain, possibility of cross infection, and emotional stress. If my child has a medical
history that may be aggravated by this course, I will consult his/her physician to
determine if my child should participate in the CPR course.
___________
Initial
I understand that various departments and clinical services at Ashley County
Medical Center will allow my child to observe in situations and participate in
activities. Ashley County Medical Center will avoid subjecting my child to
unnecessary or unusual hazards.
___________
Initial
I am aware that my child will be expected to follow instructions, to be punctual, to
be courteous, and to avoid unsafe acts. This will include respecting confidentiality,
following a specified dress code, and refraining from using a cell phone during the
program.
___________
Initial
I understand that Ashley County Medical Center retains the ultimate responsibility
for the care of patients and may request that a C*H*A*M*P*S student be dismissed
whose performance is unsatisfactory or whose actions may interfere with
performance during a clinical observation period.
___________
Initial
I / we grant permission for my son/daughter to be photographed during all CHAMPS
activities and for those photographs to be used by the CHAMPS program for any
publicity necessary.
___________
Initial
I/we grant permission for my son/daughter to be transported to and from CHAMPSsponsored activities.
___________
Initial
I/we understand the confidentiality rule and agree to adhere to the outlined policies.
I/we have read the enclosed letter from the CHAMPS director and understand what
is expected of me as a participant/parent of a participant in CHAMPS.
___________
Initial
Please sign after you have read and initialed all the above statements.
_______________________________________
Print Name
__________________________________
Relationship to Child
____________________________________________________________
___________________________________________________
Signature
Date
PHOTOGRAPHY RELEASE AGREEMENT
I, the undersigned, hereby give Ashley County Medical Center , their legal representative, assigns, and those acting on their behalf and
with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in
conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by the ACMC or those acting
on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used
in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without
restriction or limitations.
I hereby release, discharge, and agree to save harmless ACMC, their assigns, legal representatives, agents, and those acting on their
behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite
form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by
processing or reproduction of the finished product, its publication or the distribution of same.
I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.
I hereby warrant that I have read this agreement in its entirely before affixing my signature thereto, and I fully understand the contents
therein. I further warrant that I am of legal age and competent to contract my own name as far as the above is concerned.
DATE________________________________
PRINT NAME___________________________________________________________
ADDRESS______________________________________________________________
CITY_________________________________________STATE_____________ZIP__________
PHONE_____________________________________________________________________
SIGNATURE________________________________________________________________________
I warrant that I am the parent and/or guardian of
PRINT
NAME________________________________________________________________________________the
person named in the foregoing Release Agreement, and that I am duly authorized to act in his/her behalf. I have
read the foregoing agreement in its entirety and I understand its contents. I hereby consent that the photography
taken under this agreement may be used for the purposes set forth therein.
DATE____________________________________
PRINT NAME_______________________________________________________________
PRINT NAME_______________________________________________________________
ADDRESS__________________________________________________________________
CITY_________________________________________STATE____________ZIP___________
PHONE_____________________________________________________________
SIGNATURE______________________________________________________________________
STUDENTS: PLEASE DETACH AND KEEP THIS SHEET FOR YOUR RECORDS
Hello!
As the CHAMPS Program Coordinator for Ashley County Medical Center. I want you to know that we are
excited about your interest in a health career and your desire to enhance your knowledge and gain experience
within this field. Thank you for taking the time to seriously consider this program as you make plans for the
summer. Students are selected based on GPA, an essay describing their desire to attend CHAMPS, teacher
recommendation, extra-curricular activities and community service, as well as awards and accomplishments.
A committee made up of faculty and physicians will review all applications and assist in the selection process.
Please take the time to have a teacher proofread your application for any misspelled words or mistakes. If you
have any questions, please feel free to email me at any time. If you don’t have an email address, create one,
but make sure it sounds professional. ALL students who apply for CHAMPS will be notified of their status by
mail by April 20. If you have not received a letter by then, please contact me.
If you are not sure what to expect, here’s a little information about our camp.
I look forward to reading over your applications and learning more about you!
Shawna Hawkins
CHAMPS Program Coordinator
Ashley County Medical Center
Shawna.hawkins@acmconline.org
870-364-0563
Shirley White
shirley.white@acmconline.org
870-364-1272
CHAMPS, or Community Health Action in Medical Public Service, is a one-week summer camp that introduces
JR high school students who are currently in the 7th – 9th grade to health careers. Students selected into the
CHAMPS program shadow 5 days in a variety of health care locations, learn medical terminology, take part in
hands on activities to learn medical procedures, as well as a tour of Ashley County Medical Center. Students
also take part in team building activities, proper wrapping techniques and casting, as well as learning about a
variety of health careers and education levels needed for different careers. It’s too much to list, but we cover a
lot over these two weeks!
Students accepted are required to attend Monday-Friday, 8:30-4 pm. Lunch and snacks are provided.
This program is located at Ashley County Medical Center in Ashley County. We are housed hospital. We do
not provide transportation or housing for this program. Students selected should make arrangements for their
own transportation.
This is a FREE program for students, thanks to community donations and support from UAMS Regional
Programs, and the Arkansas Medical Mentor Partnership.