FACES Summer Medical Academy 2025 Waitlist

FSMA Registration 2025 – Waitlist

Thank you for your interest in the FACES Summer Medical Academy. Registration for this year’s program is now full. In order to join the waitlist, please complete the following form. Applicants will be contacted in the order received if spots become available.

Dates: June 16 – 27, 2025
Times: 9:00am – 3:30pm, Monday – Friday
*No programming on Thursday, June 19th in recognition of Juneteenth
Location: Samuel Merritt University

Program Tuition: $2,800

PART A: STUDENT INFORMATION

First Name: *

Last Name: *

Student Email Address: *

Student Phone: *

Age: (15+ required) *

High School: *

Grade: *

Current GPA: *

Mailing Address: *

Mailing Address:

City

State/Province

Zip/Postal

How did you hear about us? How did you hear about us?

What is your T-shirt size?

Parent/Guardian Full Name: *

Relationship to Student: *

Parent/Guardian Email Address: *

Parent/Guardian Phone Number: *

PART C: EXPECTATIONS/CODE OF CONDUCT

STUDENT EXPECTATIONS
The FACES Summer Medical Academy (FSMA) has a long history of excellence. The FSMA offers high school students a unique opportunity to learn about the field of health care and public health directly from experts. Students are expected to attend all workshop sessions, complete required assignments, and participate in workshops. We anticipate that students will be inquisitive and ask questions of the presenters, and will engage with their classmates during group activities and in main sessions as appropriate.

Students are expected to treat presenters, classmates and staff with respect at all times. FSMA covers sensitive topics and there may be varied opinions or experiences expressed during workshops. FACES works to create a safe space for all students to learn and the staff expects students will hear each other out, will make room for diversity of thought and experience, and will use professional interpersonal communication skills when participating in dialogue. At FACES, we assume “good intentions” of one another.

By signing below, I acknowledge that I have read and understand the expectations of me during the FACES Summer Medical Academy and I commit to meeting these expectations.

Signature of Student: *

Date

PARENT/GUARDIAN EXPECTATIONS
As the parent/guardian, by signing below I affirm that I have read and understand the above-stated expectations of my student for attending the FACES Summer Medical Academy and commit to ensuring my student meets these expectations.

Signature of Parent/Guardian: *

Date

PART D: EMERGENCY MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION

Emergency Contact Name: *

Relationship to Student: *

Emergency Contact Phone: *

Email: *

STUDENT MEDICAL INFORMATION

Health Insurance Provider *

Does the student have any allergies (food, medication, etc.)? *

Health Insurance Group Number *

Does the student have any dietary restrictions? *

Primary Care Provider *

Does the student have any medical conditions that our staff should be aware of? *

Health Insurance Policy Holder *

Please provide any specific instructions or additional information that may be relevant in case of an emergency.

CONSENT FOR EMERGENCY TREATMENT
As the parent/guardian, by signing below I authorize FSMA staff to seek emergency medical treatment for the student, in the event of an accident or sudden illness. I understand that every effort will be made to contact me prior to any such action.

Parent/Guardian Signature *

Date *

PART E: MEDIA CONSENT

AUTHORIZATION AND CONSENT TO PHOTOGRAPH AND PUBLISH
I authorize the FACES Summer Medical Academy (FSMA) at the Public Health Institute (PHI) to photograph and use the likeness of my student whose name is stated above my signature line.

I agree that:
FACES for the Future and PHI may record my participation and appearance on photograph, video, audio, and any other medium for purposes including, but not limited to, dissemination to organization staff or members of the public for educational, public relations, and charitable purposes and that such dissemination may be accomplished in any manner including, but not limited to, slide shows, brochures, advertisements, video, internet/web sites, and film. I have entered into this agreement in order to assist educational, public relations, and charitable goals and waive any right to compensation for such uses. I and my successors hold the above mentioned organization, photographer, the program staff, and their successors harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement.

Yes, I give authorization and consent to photograph and publish.

No, I do not give authorization and consent to photograph and publish.

Student’s Full Name *

Parent/Guardian Name *

Phone *