The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

2016- 2017 MassAHEC HOSA Membership Application

Instructions: This form will take 5-10 minutes to complete and must be done all at once. If you are under 18 years of age, application needs to be filled out with your parent/guardian as you will need their permission and signature. If you have any questions or concerns, do not fill out this application and ask your chapter advisor.

MassAHEC HOSA is the state affiliate of Health Occupations Students of America (HOSA) a national student organization of Future Health Professionals endorsed by the U.S. Department of Education. The program is hosted by the University of Massachusetts Medical School (UMMS), MassAHEC Network. The mission of the program is to promote career opportunities in healthcare fields to high school and college students. Some MassAHEC HOSA activities will occur after school and/or weekends. Your time commitment will vary depending on the chapter's program of work and can average 2-3 hours weekly.

First Name:

* must provide value

Middle Initial:

Last Name:

* must provide value

Date of Birth:

* must provide value

M-D-Y

Age

* must provide value

E-Mail Address:

* must provide value

Gender:

* must provide value

Female Male Do not want to report

reset

Hispanic/Latino:

* must provide value

Race:

* must provide value

African American/Black

American Indian/ Native American

Asian

Native Hawaiian or other Pacific Islander

White

More than one race

Do not want to report

Unknown

reset

Chapter:

* must provide value

Name of School Chapter not listed:

* must provide value

Current Grade or College Level:

* must provide value

Home Address:

* must provide value

City/Town:

* must provide value

Zip Code:

* must provide value

Best phone number to reach you:

* must provide value

Parent/Guardian name(s):

* must provide value

Parent/Guardian telephone:

* must provide value

Do you speak another language?

* must provide value

Yes

reset

If yes, which other language?

* must provide value

Do you have any paid work or volunteer experience?

* must provide value

Yes

reset

If so, please explain.

* must provide value

Expand

What other extracurricular activities are you involved in and what is the schedule?

Expand

I plan to pursue a career in healthcare.

* must provide value

Yes

reset

If yes, what three types of health career(s) interest you?

* must provide value

Biomedical Engineering

Chiropractics

Dental Hygiene/Tech

Dental Doctor

Medical Doctor

Medical Research

Mental Health

Nursing

Nutrition

Pharmacy

Physician Assistant

Respiratory Therapy

Ultrasound

Veterinary Medicine

X-Ray Technician

I am interested in working in communities where there is a high need for health care services and health care professionals.

* must provide value

Yes

reset

I am interested in working in a rural area (not a big city)

* must provide value

Yes

reset

Terms of Acceptance and Electronic Signature

- As a Member of MassAHEC HOSA, I agree to attend meetings regularly and arrive on time, participate positively in the group activities, show respect toward all other members, and take responsibility for my actions.

- I give MassAHEC HOSA at the UMass Medical School (UMMS) permission to periodically track my postsecondary enrollment and graduation status to gather and report accurate information about the effectiveness of the program as required by federal funding guidelines. I authorize MassAHEC HOSA to submit personally identifiable information (name, date of birth) to the National Student Clearinghouse (NSC) in connection with postsecondary status tracking efforts. The NSC will never sell student lists for commercial purposes. Every safeguard will be taken to ensure secure storage of this confidential information, and the information will not be used for any other purpose.

- I also grant permission to UMMS to obtain and publish information about my participation in MassAHEC HOSA activities with a quotation, photograph, videotape, digital or print media, or on the organizational website. I understand that UMMS may share my images with funders of this program (i.e. US Department of Health & Human Services, MA Department of Elementary & Secondary Education).

- I understand this consent is voluntary and that once disclosed, MassAHEC HOSA and UMMS no longer have control over the identifying information and images. I release MassAHEC HOSA, and UMMS and their employees from liabilities that may arise from publication of such information and images.

Student Member Electronic Signature

* must provide value

e-signature

* must provide value

By checking this box I understand that entering my name and last name in the field above constitutes a legal signature confirming that I acknowledged and agree to the above Terms of Acceptance.

Date

* must provide value

M-D-Y

Signature of Parent/Guardian if student is under 18 years of age.

* must provide value

Parent's e-signature

* must provide value

By checking this box I understand that entering my name and last name in the field above constitutes a legal signature confirming that I acknowledged and agree to the above Terms of Acceptance.

Parent's e-mail address

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.