Freeman Health Academy Student Application

Submit your Freeman Health Academy application through our safe, secure web form.

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Student Information

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First name
Middle initial
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Last name
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Gender
Race/ethnicity (optional)
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Last 4 digits of social security number (SSN)
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Birth date (mm/dd/yy)
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Street address
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City
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State
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Zip code
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Home phone (123-456-7890)
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Cell phone (123-456-7890)
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Email address
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School name
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Grade level
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Hoodie size
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Interests












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Workshop(s) you plan to attend




Special needs (if applicable)
Food allergies (if applicable)
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Name of person enrolling student
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Relationship to student

Parent/Guardian Information

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First name
*
Last name
*
Street Address
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State
*
Zip code
*
Home phone (123-456-7890)
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Cell phone (123-456-7890)
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Email address

Alternative Emergency Contact Information

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Emergency contact first and last name (different than parent/guardian)
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Home phone (123-456-7890)
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Cell phone (123-456-7890)

Other Information

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Preferred form of contact
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Do you plan to work in healthcare after graduation from high school and/or college?
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Do you have friends or relatives who work in healthcare?
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Do you know anyone who works at Freeman?
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From what you know, do you consider Freeman to be a great place to work?
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How did you hear about Freeman Health Academy? (Check all that apply)