Christ Clinic Katy / Volunteer / Summer Institute 2017

The Summer Institute is a yearly program in which pre-medical students come to Christ Clinic for an intensive 6-week experience in the summer. Participants see all aspects of patient care and work through our curriculum that emphasizes integrating faith and the practice of medicine. Students will engage in this curriculum with our medical director, Dr. Cindy Anthis.

The program is open to all college students who have completed at least one year of their studies.

Application deadline is March 16, 2018 at 5:00 PM. Applicants must be available for an interview March 19-30 (via in-person or Skype).

Acceptance notifications will be sent on April 2, 2018. Only 4 students will be selected for Summer 2018.

APPLICANT INFORMATION

First and Last Name

Mailing Address

City, State and Zip Code

Phone Number

Email Address

SESSIONS

The summer will be divided into 2 sessions. Each student will be asked to committ to one session and work 25 - 30 hours each week during the session.

Please email a copy of your resume along with two letters of reference (preferably, one from an organization you have volunteered with) to Vista@christclinickaty.org.

Check the session you are interested in attending

SESSION 1: May 21 - June 29

SESSION: 2: July 2 - August 10

DEMOGRAPHICS

Current school

Expected Graduation Date

Future plans (MD. NP, PA, Nursing or Other)

How did you hear about the program?

Can you speak Spanish?

Fluent

Moderate

Minimal

ESSAY QUESTIONS

What are your long term goals? How will this experience impact that? (Answer in 250 words or less)

Who, in your opinion is Jesus Christ and how do you relates to Him? (Answer in 250 words or less)

SPECIAL SKILLS & QUALIFICATIONS

Summarize special skills and qualifcations you have acquired from employment, previous volunteer work or through other activities, including hobbies or sports.

Why do you want to participate in Christ Clinic's Summer Institute?

EMERGENCY CONTACT INFORMATION

Name

Address

City, State and Zip Code

Contact Phone Number

E-mail Address

Do you have any allergies?

Yes

If yes, please list.

Have you been previously screened for TB (Tuberculosis)

Yes

Date of last screening

T-Shirt Size

Small

Medium

Large

X-Large

Media Release

We request your permission for your participation. By indicating below, you may choose to grant or deny Christ Clinic permission to use photographs, video of yourself or in a group for newsletters, social media postings, brochures, special fundraising activities for use in public understanding and support of Christ Clinic programs and services.

I give permission to be videotaped and/or photographed by Christ Clinic.

I do not give permmission to be videotaped and/or photographed by Christ Clinic.

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal.

Name

Date

Our Policy

Its the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age or disabilty.

Thank you for completing this application form and your interest in volunteering with us.

Thank you for applying to the Summer Medical Institute at Christ Clinic. Your application will be reviewed by our committee once your references have been received and we will contact you to arrange an interview (The interview can be in person or via phone or Skype. ) Thank you again for your interest in this program.

Summer Institute 2018