Individual 14-17 Youth - Hopkins Medicine Youth/Undergraduate and Summer Opportunities Registration

Instructions

Johns Hopkins University School of Medicine's (JHUSOM) Office of Student Pipeline Programs oversees the registration, approval process, and verification of required documents in order for youth/undergraduates to receive a JHUSOM ID badge during the academic year and for any summer program.

THE DIRECTOR OR ADMINISTRATOR OF THE PROGRAM SHOULD COMPLETE THIS FORM. DO NOT LET YOUR PARTICIPANTS COMPLETE THIS FORM.

This form needs to be filled out for every program participant (paid or unpaid) between ages 14-17 years old. There is another form for participants who are 18 years old and above.

The information is needed to be in compliance with university, state, and federal policies. Note that it may take 2 to 3 weeks to collect/verify required information for this form, so please plan accordingly.

For more information, please email SOMYouthPrograms@jhmi.edu.

* Required

Program Information

Individual Participant Information

This form is for participants who are between 14 and 17 years old before the start of your program.

Will this participant be working with any of the following? (Select all that apply) *
Additional training and documentation may be required if this participant is working with any of the following. Training will be the responsibility of the individual programs.
Enter name exactly as it appears on official documents.
Enter name exactly as it appears on official documents.
Enter name exactly as it appears on official documents.
Gender (optional)
Johns Hopkins University records the demographics of participants. This is helpful to understand who Hopkins is serving through these programs.

Race (optional)
Check all that apply.

Emergency Contact Information

This information will enable program directors to contact the parent/guardian in case of an emergency.

Parent/Guardian Address