Future Health Leaders: Care Begins Here Application

Legal First Name

Preferred First Name

Legal Middle Name

Legal Last Name

Birthdate

Email

Mobile Phone

Do we have permission to text you with important information and updates?

YesNo

Mailing Address Line 1

Line 2

City

State

Country

Zip/Postal Code

Gender Identity

Pronouns

Are you a US Citizen, permanent resident, or hold refugee status in the US?

YesNo

What is your current grade level?

Anticipated College Entry

e.g. Fall 2026

Where do you currently go to high school?

List the clubs, sports, and/or activities you participate in both inside and outside of high school

Have you attended a previous conference with us?

Yes, virtual conference Yes, in person conferenceNo

How did you hear about this program?

In a paragraph or two, please explain why you want to participate in Future Health Leaders: Care Begins Here.

List and briefly describe three strengths you will bring to this camp. (i.e. skills, passions and personal attributes)

What excites you most as a future health leader, and what problems are you interested in solving related to health or healthcare?

Anything else you'd like to tell us?

Parent/Guardian 1 information

First Name

Last Name

Phone

Email

Parent/Guardian 2 information (optional)

First Name

Last Name

Phone

Email