2026 Summer Enrichment Program (SEP) Application

Lakeland Regional Health Summer Enrichment Program Application

Program Dates: July 6, 2026 - July 31, 2026 (Mondays, Wednesdays, Fridays, 9:00 a.m. - 4:00 p.m

Thank you for your interest in the Lakeland Regional Health Summer Enrichment Program! This immersive, hands-on program is designed to expose high school students to healthcare, offering insights into various career paths and the patient care journey. Please complete this application carefully. Applications are due by Friday, March 13.

The program welcomes rising 10th graders through rising seniors, ages 15 to 17.
Section 1: Personal Information
1. Full Name*
2. Date of Birth MMDDYYYY*

MonthDayYear
Date
3. Age as of July 1, 2026*
4. Gender*

MaleFemalePrefer not to disclose
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. Student's Primary Phone Number*
Please enter a valid phone number.
7. Student's Primary E-mail Address*
example@example.com
Section 2: Academic Information
Current School Name*
Rising Grade Level (for the 2026-2027 school year):*

10th11th12th
Are you currently enrolled in a medical academy or healthcare program at your school?*

YesNo
List any healthcare related courses extracurriculars or certifications*
Current GPA
Lakeland Regional Health also has a summer teen volunteer program for students looking to earn volunteers hours. Are you interested in participating in this program as well?

YesNo
Section 3: Availability and Commitment
Are you available for the program dates (July 6, 2026 - July 31, 2026)*

Yes, I can commit to attending all sessions.No, I have a conflict. (please specify below)
Please specify your conflict below:
Do you have reliable transportation to and from the program location?*

YesNo
Section 4: Personal Statement
In 300 - 500 words, please answer the following questions:

Why are you interested in participating in the Lakeland Regional Health Summer Enrichment Program, and how will this experience contribute to your future goals in healthcare?
Personal Statement
Section 5: Parent/Guardian Information
1 Parent/Guardian Full Name*
2. Relationship to Student:*

MotherFatherLegal GuardianOther
3. Parent/Guardian Phone Number*
4. Parent/Guardian Email Address*
example@example.com
6. Emergency Contact Name*
3. Emergency Contact Phone Number*
Section 7: Agreement & Signatures
By signing below, the student and parent/guardian affirm the following:
1. The student is committed to attending the Lakeland Regional Health Summer Enrichment Program for all scheduled days and times.
2. The student will adhere to all program guidelines and expectations.
3. The parent/guardian permits the student to participate in this program, including any off-site activities, if applicable.
Student Signature*

Clear
Date*

MonthDayYear
Date
ParentGuardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Section 1: Personal Information

Section 2: Academic Information

Section 3: Availability and Commitment

Section 4: Personal Statement

Section 5: Parent/Guardian Information

Section 7: Agreement & Signatures