Program Application

Application for AMPHL Youth Program
A youth program at the Association of Medical Professions with Hearing Losses Conference for Deaf/Hard of Hearing students

June 20-23, 2024 Visit Program Site

Program Dates:

Session I: June 20-23, 2024

Please complete and submit this application. We must receive the following required information before we can consider your application:

- A copy of your official high school transcript (from ninth grade to present)

- A copy of your unaided audiogram (results without a hearing aid or cochlear implant)

- Your personal essay explaining why you want to be selected for the AMPHL Youth Program

Please Note:

This is intended for high school students currently in 10th, 11th, and 12th grade who are interested in medicine.

Student

Personal

First

Preferred Name

Last

Birthdate

Year of Graduation

Gender

Male

Female

Nonbinary

Other

Pronouns Used

He/Him

She/Her

They/Them

Other

Contact

Address

City

State

Zip

Country

Phone

Shirt

Shirt Size

XXL

3XL

4XL

All shirt sizes are adult sizes

Misc.

Communication Preferences

Speech & Lipreading (I do not use sign language)

American Sign Language Only

Speech & American Sign Language

Parent/Guardian

Personal

First

Last

Duplicate Student Address

Address

City

State

Zip

Country

Fax

Home

Work

Cell

Misc.

What language does your family use at home?

Academics

School

Name

Address

City

State

Zip

Country

Counselor

First

Last

Fax

Phone

Additional Information

Please list any known Food Allergies

If you wish to be identified with a particular ethnic group, please select the appropriate one.

African American, Black

Asian American

Native American, Alaskan Native

Hispanic, Latino

Native Hawaiian, Pacific Islander

White, Caucasian

Other

If you have taken any of the following college entrance tests, please indicate your score in the appropriate box below:

PSAT

PSAT Selection Index (sum of the critical reading, math and writing scores)

SAT

SAT Total score (sum of the critical reading, math and writing scores)

ACT

ACT Composite Score

How did you first find out about this program?

Received information from RIT/NTID

Saw the advertisement or article in:

Found out about it from my school counselor or teacher

Found out about it from a friend or family member

Read about it online

Other

Please type in the word indicated by the image below:

Questions:

Videophone: 585-270-0067
E-mail: jamnca@rit.edu

Application for AMPHL Youth Program A youth program at the Association of Medical Professions with Hearing Losses Conference for Deaf/Hard of Hearing students

June 20-23, 2024 Visit Program Site

Student

Parent/Guardian

Academics

Additional Information

Application for AMPHL Youth Program
A youth program at the Association of Medical Professions with Hearing Losses Conference for Deaf/Hard of Hearing students