To apply for the UCHealth Junior Medical School (JMS) Program, students must meet the following criteria: must be 16-18 years of age, and be a junior, senior or graduating senior in high school. Please complete this application form in its entirety. Once you have completed the form, click the "continue" button at the bottom of this application in order for it to be entered into our database. A complete application packet includes - this application, an application fee of $25, and two Letters of Recommendation. Program will be limited to 12 students - only - per session.

COVID Disclaimer: Due to the unpredictability of Covid, please note the following:

  1. Sessions may be cancelled at any time if infection rates get too high
  2. If your session gets cancelled, there will be no make-up session
  3. All applicants/accepted students must submit proof of a Covid vaccine
  4. Masks must be worn at all times during the program
  5. Payment for the program may be made no sooner than 1 week prior to the start of the session or you can bring a check on Day 1 of the program (payment link is on the web page)

Applicant Information


Demographics

Please provide the following information. This information is not shared nor used in determining participant acceptance. It is used to help us get a better understanding of the demographic make-up of our applicants.



Sessions

In order for us to schedule you effectively, please pick ONE session that you are interested in attending that works with your summer schedule.


Session I & ll - Application Deadline - April 29 

Session III & IV - Application Deadline - May 27



Getting to Know You

Answer the following questions below in the box provided below. Please remember to number your answers to the corresponding question.


1. What are your career goals?


2. List any activities/programs you are participating in to achieve these career goals.


3. Do you have any volunteer or work experience relating to healthcare? If yes, please  explain.


4. What do you hope to learn from participating in this program? Please elaborate on your answer.


5. What unique personal characteristics or traits make you the best applicant for this opportunity? Please provide an explanation.


6. Discuss how your view of yourself and your world have been expanded as a result of exposure to a book, story or experience and explain why.



Emergency Contact

In the event of an emergency who can we notify? Please list only those that can make decisions for you legally from the relationship box below.



Release Authorization

CONSENT AND LIABILITY RELEASE FORM

I hereby consent to participate in the UCHealth Junior Medical School (JMS) Program. I understand the purpose of this opportunity is to gain experience by interacting with healthcare professionals at Memorial Hospital in their day-to-day work and classroom environments to further my interest in a healthcare career.


RISKS

I understand that I will be working with hospital professionals as they respond to requests for medical care and services. I further understand that in responding to such requests, I may be exposed to conditions and situations that may be dangerous and traumatic. Such conditions and situations include, but are not limited to, exposure to hazardous materials/chemicals, exposure to communicable diseases transmitted through exposure to blood, body fluids, airborne pathogens, and risk of physical harm as a result of a combative patient. I further understand that my exposure to such conditions and situations may result in illness, injury and a risk of emotional harm that may accompany my exposure to graphic or traumatic scenes that may include trauma injuries and or death. I also acknowledge that I may be exposed to risks that cannot be anticipated. I further understand that the hospital professionals’ obligations are to render care and treatment to patients first and therefore the hospital professional may not be able to protect me from the various risks to which I may be exposed.


RELEASE

I acknowledge that there are risks involved in my participation in the program as listed above and hereby agree to hold harmless and forever release UCHealth and its trustees, officers, directors, employees, representatives, and agents from any and all actions, claims, demands or damages that I, my assignees, heirs, guardians, next-of-kin, spouse and legal representatives now have, or may have in the future related to any illness or loss that I may experience, including any physical or emotional injury, as a result of my participation. I acknowledge and approve the opportunity for a blood draw to learn my blood type as part of the lab portion of the program and allow that process to be completed. I acknowledge I will be shown basic medical suturing techniques and given opportunity to practice these demonstrations. This in no manner should be taken as a formal education of suturing techniques and does not represent a qualified medical procedure.


CONFIDENTIALITY

I further acknowledge that in the course of this experience, I may become aware of facts relating to patient identity and private healthcare information, such as diagnosis, treatment, complaints or financial information. I fully understand that all patient health information (PHI), identity and all the facts relating to the care and treatment rendered by the UCHealth professionals are strictly confidential, both ethically and legally. I understand that at no time can any such information be discussed even after I complete my participation in the JMS program. I understand that I am expected to comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), as well as other applicable laws and internal policies of UCHealth.


IMMUNIZATION STATUS

I represent that my immunizations are current and up to date. If participant is under 18 years of age, the parent or legal guardian must also sign at the end of this application. I confirm I am the parent or legal guardian of the volunteer participant listed above and I give my unqualified permission and consent for my son or daughter to participate in the UCHealth Junior Medical School (JMS) Program, under all of the terms and conditions enumerated in this Consent and Liability Release. I represent that my child’s immunizations are current and up to date.



Application Information and Fees

Please note only COMPLETE application packets will be considered for acceptance. A complete application packet includes - this application, an application fee of $25 and two Letters of Recommendation. There is a one time, non-refundable application fee of $25 to apply for the program. I understand if accepted into the program, there is a program fee of $200 due by the start of my selected session or I can also bring a check with me on Day 1 of the program. If I am unable to pay for the program, I understand a limited number of need-based scholarships are available for financial assistance.

If interested in applying for a need-based financial scholarship, please check the box below and provide a brief explanation of circumstances regarding the request.

All fees can be paid in person by cash or check only, or on our website (www.uchealth.org) with the credit card link provided.



Letter of Recommendation Requirements

Applications require two Letters of Recommendation - one personal, no family members please, and one professional such as a counselor, teacher, coach, clergy, etc. Please submit your Letters of Recommendation to beth.konikoff@uchealth.org, within five business days of the application date. It is the student's responsibility to ensure the timely submission of both letters. Students without complete applications will NOT be considered.



Signature Requirements

All participant applications under the age of 18, must have a parent/legal guardian electronic signature/consent in the box provided at the end of this application. All participants must also sign in the Student Signature box at the end of this application.


PARENT/LEGAL GUARDIAN CONSENT:

My son/daughter has my permission and full support to participate in the UCHealth Junior Medical School (JMS) Program.


Electronic Signature:

Submitting an application through this website constitutes your electronic signature. Any record containing an electronic signature shall be deemed for all purposes to have been “signed” and will constitute an “original” when printed from electronic records established and maintained by UCHealth in the normal course of business. Upon UCHealth's request, user agrees to sign or place user's signature on any paper original of any electronic record that UCHealth provides to user containing user’s purported electronic signature.




Disclaimer

I understand and agree that submitting this application form does not automatically guarantee acceptance into the UCHealth Junior Medical School (JMS) Program. I attest that the information I have provided on this application is true and accurate and that I meet the criteria required to be a participant of the program and have submitted the forms and payment listed below.


1. I am 16-18 years of age

2. I am a junior, senior or graduating senior in high school

3. My Immunization Status is up to date to include my COVID 19 vaccine and Flu Vaccine

   (if seasonally applicable)

4. I have paid my $25 Application Fee

5. I have supplied my two Letters of Recommendation