FSMA 2022 Registration

FSMA Registration 2022

FSMA Session 1 - The Health Academy: Preparing to Manage Crisis as a Health Professional
Deadline to apply: Friday, July 1, 2022 11:59pm PST
In this one week hybrid experience (both in-person and online learning) students will practice valuable skills that can be leveraged in an emergency situation. All students will be professionally certified in Mental Health First Aid (to identify signs and symptoms of mental health challenges and respond to crises such as panic attack and thoughts of suicide), Basic Life Support/CPR (to intervene during a medical emergency), Stop the Bleed (for use in trauma and accident) and Narcan training (for opioid overdose intervention). Not only will these professional certifications make students more competitive when applying to college, certification or employment – but students will be trained as youth leaders ready to support their community in a time of crisis. The skills developed during this week will last a lifetime – and may even be used to save a life!

FSMA Session 2 - Medical Mystery: Learning the Process of Diagnosis
Deadline to apply: Friday, July 8, 2022 11:59pm PST
In this week-long virtual experience, you’ll work in small teams to solve the medical case of a 22-year-old woman with undiagnosed health issues. You’ll learn about the process of differential diagnosis as details of the patient’s symptoms and life are revealed. Along the way, you’ll consult with real health professionals, receive mentorship from FACES staff, and develop a comprehensive treatment plan for your patient. Through this interactive experience, students will learn about the intersection between clinical health care, public health, mental health and how to incorporate cultural humility into practice.

Please note that payment in full is due at the time of registration. You will be directed to PayPal upon submission of the completed registration form.

PART A: STUDENT INFORMATION

First Name: *

Last Name: *

Student Email Address: *

Student Phone: *

Age: (15+ required) *

High School: *

Grade: *

Current GPA: *

Where do you plan to join virtual sessions from? (ex: my home, friend's home, grandparent's home, etc.) *

Mailing Address: *

Mailing Address:

City

State/Province

Zip/Postal

How did you hear about us?

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. Even though the format of our program has changed to include both in-person and virtual programming, our expectations of FSMA students have not. Students are expected to attend all workshop sessions, complete required assignments, and participate in in-person sessions and virtual workshops on Zoom with their camera on. We anticipate that students will be inquisitive and ask questions of the presenters verbally or through the chat feature, 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.

The FACES Coalition staff will be reviewing and revising COVID-19 policies and procedures as we get closer to program dates of service. Students will be required to comply with any COVID-19 policies that may be in place at that time which could include requirements such as proof of vaccination, masking and physical distancing. These requirements will be communicated to students prior to the start of the program and will follow guidelines of the program site, Public Health Institute and the Alameda County Department of Public Health.

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 CONTACT

Please provide the name, phone number and email of someone the FSMA staff can contact in case of an emergency with your student during FSMA workshops.

Name: *

Relationship to Student *

Phone *

Email *

Will this individual be in the same location as the student during virtual workshops? *

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:

FSMA 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. FSMA may also use the images prepared from screen-captures from Zoom class sessions for such purposes, as well as to provide video recordings of the sessions to students should they miss a workshop. The term "screen-capture," as used in the foregoing agreement, shall mean motion picture or still photography in any format, as well as videotape, videodisc, and any other mechanical means of recording and reproducing images.

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.

Consent: *

Yes, I give authorization and consent to photograph and publish

Yes, I give authorization and consent to photograph, for internal use only (eg. recording a workshop when a student misses class or for staff training). I do not give consent to publish

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

Student's Full Name *

Parent/Guardian Name *

Phone *

Parent/Guardian Signature *

Date *

Address *

Address

City

State/Province

Zip/Postal

PART F: FSMA SESSIONS

FSMA Session 1 - The Health Academy: Preparing to Manage Crisis as a Health Professional
When: July 11- July 15, 2022
How: Hybrid programming
Where: In-person workshops held at CSU East Bay Oakland Conference Center; Virtual workshops held via Zoom
*Note: The Mental Health First Aid Certification Course in this session requires the student to complete 2 hours of pre-work prior to the start of the session. In registering for this course, you are acknowledging that the completion of this pre-work is expected of the student.

FSMA Session 2 - Medical Mystery: Learning the Process of Diagnosis
When: July 18 - July 22, 2022
How: Virtual programming
Where: Zoom
*Note: A mandatory Welcome & Orientation will be held via zoom Friday, July 15th, 2022 from 3:30-4:30pm

COURSE REGISTRATION: *

FSMA Session 1 Only - $1500

FSMA Session 2 Only - $1000

FSMA Session 1 & 2 - $2200

TOTAL PAYMENT DUE:

PART G: PAYMENT INFORMATION

REFUND POLICY:
Payment is due in full via PayPal upon submission of registration form.
* Cancellation notifications received at least 7 days prior to the first day of class will receive a 50% refund.
* Registration cancellation notifications received less than 7 days prior to the first day are not eligible for any refund.
* Should your course be cancelled due to low enrollment, you will receive a full refund for the cancelled course.

Did you review your selections carefully? Did you review the Refund Policy?
By clicking on the Submit & PayPal button below, you are acknowledging that you have read and understood the Refund Policy. You will be taken to PayPal to pay for the full registration fee. Your registration will not be complete until payment has been received.