SWCAHEC Health Careers Institute Mentor Student Application 2022

For Mentors June 7-10th, 2022 Free Health Careers Institute
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    (all cities and towns in the Southwest region are considered rural).
    (All communities in the 8 county SWCAHEC region are considered "medically-underserved areas")
  • By initialing, I indicate my understanding, that upon acceptance into the program, my son/daughter is required to provide a copy of their up-to-date immunization records (including Covid 19 vaccines and boosters) required by Fort Lewis College.
  • I certify that the information given in this application is true & correct. I have proofread for accuracy and completeness, for I realize that applications are accepted only when complete.
  • By entering name and date above and clicking the "Submit" button below I certify that: 1) I will not hold the Colorado AHEC Program or Southwestern Colorado Area Health Education Center responsible for any accidents that may occur while my son/daughter is participating in the program or at the job shadow site during the Health Careers Institute; 2) I am the custodial parent(s) and/or legal guardian(s) of the person designated as Participant above; and 3) I am over the age of eighteen (18) years of age. This action will constitute an electronic signature in lieu of an actual signature and evidences the parties' mutual intent to enter into a valid and binding contract that will satisfy all applicable legal requirements. This Agreement shall constitute an "original" when printed from electronic files or records established and maintained in the normal course of business.
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  • This field is for validation purposes and should be left unchanged.