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Camper Application

Thanks to a generous gift from the Al Glick Scholars Endowment Fund, Henry Ford Jackson Hospital (HFJH), in partnership with the Jackson Area Career Center (JACC), is hosting our fourth annual summer day camp free of cost for thirty (30) Jackson area students currently in grades 6th – 9th.

The 2026 HFJH Al Glick Healthcare Camp takes place Monday, June 15, through Friday, June 19. Applications and required documentation must be submitted by Monday, May 11, 2026. Late submissions will not be considered.

*Asterisk indicates required field.

Student Information

Student First Name Student Middle Initial Student Last Name Student Date of Birth Name of Middle School Current Grade for the 2025/2026 School Year (Fifth, Sixth, Seventh, Eighth)

Parent/Legal Guardian Information

First Name Middle Initial Last Name Phone Number Email Address Home Street Address City State ZIP Code

Emergency Contact

First Name Last Name Relationship to Student Cell Phone Home or Work Phone

Additional Emergency Contact

First Name Last Name Relationship to Student Cell Phone Home or Work Phone

Student Short Essay

In one paragraph please share why you are interested in healthcare and want to participate in the HFJH Al Glick Healthcare Camp.

Essay

Allergies and Prescription Medications

Known Allergies Current prescribed medications student would need to be given during camp

Additional Information

Do you speak a language fluently other than English? Yes No If yes, please list How did you learn about the HFJH Al Glick Healthcare Camp? T-shirt sizes / Adult sizing (Please select one) XS S M L XL XXL

Transportation

My student will be transported via: Bus stop location Paragon Charter Academy: 3750 McCain Rd, Jackson, MI 49201 Martin Luther King Jr. Center: 1107 Adrian, Jackson, MI 49203

Parental/Legal Guardian Permission for Application

I have completed the above information to the best of my ability and understand that any falsification of the information provided above may prohibit my student’s participation in the HFJH Al Glick Healthcare Camp. If my student is selected to participate, my student and I agree to abide by all the hospital rules, regulations, and expectations. I also understand that requirements may be changed at any time in accordance with best practice and/or organizational improvements for patient/staff safety and guest experience. I understand my student will be required to complete the Henry Ford Health’s student immunization compliance standards. This includes TB skin test, current TDAP, and MMR vaccines.

If your student does not have these completed, they will need to receive these from their pediatrician. Please see the attached Camp Vaccination Checklist & Timeline to ensure all vaccinations are administered within the correct timeframe.

I understand failure to ensure my student receives all vaccinations and tests by the specified timeframes in the attached HFJH Al Glick Healthcare Camp Vaccination Checklist & Timeline will prohibit my student from participating. I understand failure to send all required information, and documents to HFJHAlGlickHealthcareCamp4@hfhs.org by Monday May 11th, 2026, will prohibit my student from participating in the HFJH Al Glick Healthcare Camp. I understand I will be responsible for coordinating transportation for my student to and from their camp location for the day or the identified bus stop.

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Camper Application

Student Information

Parent/Legal Guardian Information

Emergency Contact

Additional Emergency Contact

Student Short Essay

Allergies and Prescription Medications

Additional Information

Transportation

Parental/Legal Guardian Permission for Application

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