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*First Name:

Day Volunteer Applicaton - All counselors must be 19 years old

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*Child's Last Name

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*Title:

*Camp

Star Trails (June 19 - 24)

AOK (Aug 8 -13)

Junior Camper Day (Ages 4-5)(June 22)

MRN #

BIOGRAPHICAL INFORMATION

*I would like more information on these topics

M. D. Anderson views on the latest developments in cancer prevention
Diet and exercise
Exams that test for cancer

*I would like to nominate
[name and department]

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*First Name

*Child's Last Name

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Please complete this form to assist us in providing the best camp experience for your child. In addition, the child's Physician, Clinic Nurse and/or Nurse Practitioner at MD Anderson will also complete a camp medical form.

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as it appears on passport

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Explain how this employee has demonstrated HR BEST in Building Partnerships? (Please provide a detailed description.)

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New/Revised Template

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*Address

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Entries must be received by Friday, February 14^th 2014. One entry per employee.

Explain how this employee has demonstrated HR BEST in Engagement? (Please provide a detailed description.)

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Afternoon Breakout Sessions

Thinking: Gather relevant information; break down problems; approach problems with curiosity and open-mindedness; make sound decisions.

*E-mail

*Work E-Mail Address

*Department / Division

Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.

*Purpose

*E-mail address

*P/P is related to or initiated out of a:

Patient Safety Issue
Peer Review Issue
QI Concern/Initiative
Change in practive/standard
High Risk Issue
Problem Prone Issue
Other

Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.

Basic Instructions for Creating Templates

*Description of Project

*Description of Request

Analytical Thinking: Gather relevant information systematically; break down problems into simple components; make sound decisions.

City

Weekday mornings (8:00 a.m. - 12:00 p.m. or 9:00 a.m. - 1:00 p.m.)

1. Create template as a Notepad document. Type your template headings in the order they should appear. Save your template.

*Title of Article:

Explain how this employee has demonstrated HR BEST in Service? (Please provide a detailed description.)

2. To ensure consistency: No multiple fonts, bolding or underline; Lines formatted for 79- 88 characters per line; Insert brackets [ ] to create check boxes.

3. Attach an example of your template in the field below.

Weekday afternoons (12:00-4:00 or 1:00-5:00 p.m.)

Permanent mailing address

All abbreviations must comply with the MDACC Do Not Use Abbreviations List, http://inside.mdanderson.org/departments/joint-commission/do-not-use.html

*Zip Code

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Weekday evenings (5:00-8:30 p.m., 2-hour shift)

Saturday or Sunday (8:00 a.m. - 4:00 p.m., 4-hour shift, every other weekend)

State

P/P is related to or initiated out of a:

State

*Select all that apply

Weekday mornings
Weekday afternoons
Weekday evenings
Saturday or Sunday

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Analytical Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Sees underlying issues in complex situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Develops solutions that effectively address problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Acts decisively to solve difficult problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Focuses on important information without getting bogged down in unnecessary detail.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1.Accurately identifies situations that require guidance or assistance from others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Makes timely decisions in the face of uncertainty.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Develops solutions that effectively address problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Generates well thought-out solutions to problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

1. Focuses on important information without getting bogged down in unnecessary detail.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Effectively troubleshoots problems that arise.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Generates well thought-out solutions to problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Makes decisions based on sound logic and rationale.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2.Effectively troubleshoots problems that arise.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Makes decisions based on sound logic and rationale.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Takes all important issues into account when making decisions.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Recognizes the impact that issues may have on his or her department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Applies thorough analysis to problems that warrant this level of attention.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

2. Recognizes the impact that issues may have on his or her department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*3. Makes decisions in the face of uncertainty.

3. Effectively troubleshoots problems that arise.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3. Systematically evaluates a course of action and the potential consequences.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3. Applies thorough analysis to problems that warrant this level of attention.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3. Makes decisions in the face of uncertainty.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3.Offers new ideas for ways to more effectively approach work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3. Identifies underlying issues and root causes of problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3. Does not overanalyze problems that do not warrant the attention.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

3. Use a methodical step-by-step approach to break down complex problems or processes into their parts.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Use a methodical step-by-step approach to break down complex problems or processes into their parts.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Does not overanalyze problems that do not warrant the attention.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Considers multiple sources of a problem before developing a solution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Considers multiple sources of a problem before developing a solution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Compiles information from a variety of resources to obtain the most effective solution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Is comfortable making decisions and moving forward in uncertainty	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Is comfortable making decisions and moving forward in uncertainty.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Demonstrates respect for the processes by which decisions are made.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Considers multiple sources of a problem before developing a solution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Systematically evaluates a course of action and the potential consequences.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Acts decisively to solve difficult problems.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*7. Exercises good judgment by making well-informed decisions.
*8. Demonstrates respect for the processes by which decisions are made.

Have you previously collaborated with a faculty member of statistical analyst in the Department of Bioinformatics and Computational Biology?

Attach a file

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*Approver Name

County

State

*Zip

By submitting this form, I confirm that I attended the clinic provided on this date.

Organization:

*Address Line 1

*Target ID, Name and Domain (geneDB, EC, or genbank ID)

Service

Personal E-Mail Address

For smaller groups to discuss specific questions. Limited to the first 50 registrants per session.

*Phone

*Name of Dept Chair/Supervisor

*Check all that apply

Patient Safety Issue
Peer Review Issue
QI Concern/Initiative
Change in practice/standard
High Risk Issue
Problem Prone Issue
Other

*Supervisor's Name

Policy / Procedure Document

*Year: (Only submit articles published after 2007)

*Are you currently a student?

*Phone

*Address

Zip Code

*Primary Phone Number

*Approver Phone

Relationship to MD Anderson:

Address Line 2

*Select the highest level of degree completed.

*Target Class/Family (e.g. protease, kinase)

Breakout Session #1: 12:45 - 2:05 pm

Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.

FAX

*Has he/she been informed of your travel?

Yes

Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.

Strategic Thinking: Define strategic goals and issues clearly; apply broad knowledge and experience when addressing strategic issues; foresee obstacles and opportunities relating to change or improvement.

Innovative Thinking: Approach problems with curiosity and open-mindedness; offer new ideas, solutions and/or options.

*Supervisor's Approval of Time Commitment

Yes

Upload P/P

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*Project Purpose (What do you want to increase or decrease?)

Previous collaboration?

Yes

*How should P/P be prioritized?

Urgent

Non-urgent

Zip

Explain how this employee has demonstrated HR BEST in Teamwork? (Please provide a detailed description.)

*Have you completed the Diversity Champion Program?

Yes

Fax

*City

*Are you fulfilling a school requirement?

Yes

*Email

*Please select your employment status.

Innovative Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Strategic Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Innovative Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Innovative Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Innovative Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Innovative Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Strategic Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Innovative Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Encourages brainstorming and innovative ideas to promote change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Offers new ideas for ways to more effectively approach work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Keeps the big picture in perspective.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Drives innovation and change within the department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Drives innovation and change within the department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4.Shows compassion when dealing with difficult or challenging customers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Challenges the Institution to constantly improve.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Offers new ideas for ways to more effectively approach work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

4. Serves as a resource to help others in generating new ideas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

7. Serves as a resource to help others in generating new ideas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Challenges the Institution to constantly improve.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5.Goes above and beyond to exceed external and internal customer expectations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Supports innovation and change within the group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

7. Is open to new approaches and alternative practices that will help meet institutional goals and objectives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

7. Develops plans that contain contingencies for change or uncertainty.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Is open to new approaches and alternative practices that will help meet institutional goals and objectives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

5. Creates innovative solutions that benefit the department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Applies lessons learned or best practices to improve future work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*7. Creates innovative solutions that benefit the department.

7. Creatively integrates different ideas and perspectives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Supports opportunities for change and new ideas to improve individual, group or department performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Creatively integrates different ideas and perspectives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Supports innovation and change within the group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Translates his or her vision into realistic business strategies.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Takes calculated risks to achieve organizational success.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6. Approaches problems with curiosity and open-mindedness.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

6.Diligently follows through on customer concerns to the point of resolution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Creatively integrates different ideas and perspectives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

7.Is pleasant, courteous, and professional when dealing with internal or external customers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Creates plans that balance long-term goals with immediate needs.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Approaches problems with curiosity and open-mindedness.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Translates his or her vision into realistic business strategies.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Applies lessons learned or best practices to improve future work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Develops plans that contain contingencies for change or uncertainty.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Creatively integrates different ideas and perspectives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Creates plans that balance long-term goals with immediate needs.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*15. Aligns resources to accomplish key organizational objectives.

*Implementation Date

mm/dd/yyyy

Why are you interested in becoming a Diversity Council member?

*Indicate Your International Travel Destination (Restricted Country)

Session 1

Teamwork

*Comments (e.g. availability of cDNA, assay, inhibitors, other)

*City

Name of your MD Anderson contact:

*Cell Phone

NOTE: For questions regarding this form please contact Janice Freeman, Tracy Van Horne, LaTasha Burns, or Nicole Vaughn-Adams.

*Primary Email

*Cell Phone

*State

*Explain

*Email

What type of volunteer position interests you?

*Diagnosis

*Email

*State

*Gender

Male

Female

*Cell Phone

*Email

Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.

*City

Describe exactly what you want us to provide. With respect to protein production you may require: cloning, mutagenesis protocol development, expression system development or improvement, large or small scale protein expression and/or purification.

Breakout Session #2: 2:05 - 3:25 pm

Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.

Are forms/documents tied to the policy that will be part of the medical record?

Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.

Project Details

*TShirt:

*Requesting Continuing Medical Education (CME) credit

Yes

*Select all that apply

Direct Patient Contact
Limited Patient Contact
No Patient Contact

*Zip code

*Are you available to commit to volunteering for at least six months?

Best Time to Call

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Strategic Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Strategic Thinking	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

7. Shows compassion when dealing with difficult or challenging customers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Effectively coordinates resources to carry out projects or initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Manages aggressive yet realistic timeframes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Builds alliances and partnerships across the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8.Adheres to the behavioral standards expected by the department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Shows compassion when dealing with difficult or challenging customers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

7. Relates well to people regardless of their title, personality, or background.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Supports and champions the initiatives of others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Establishes open, candid, and trusting relationships.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Builds alliances and partnerships across the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Goes above and beyond to exceed external and internal customer expectations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Works quickly to resolve conflicts when they arise.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9.Is trusted by others in the work group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Monitors progress of others and redirects efforts when goals are not being met.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

8. Goes above and beyond to exceed external and internal customer expectations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Relates well to people regardless of their title, personality, or background.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Effectively coordinates resources to carry out projects or initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Collaborates across boundaries, finding common ground with a wide range of stakeholders.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*12. Leads an inclusive workplace that maximizes the talents of each person.

11. Diligently follows through on customer concerns to the point of resolution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Works quickly to resolve conflicts when they arise.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Diligently follows through on customer concerns to the point of resolution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10.Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Translates business strategies into clear objectives and tactics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

9. Promotes practices that are sensitive to the needs of a diverse workforce.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18. Seeks out relationships across the Institution that are mutually beneficial.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Makes sure systems and processes are in place to complete the work efficiently.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11.Holds self accountable for meeting commitments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Monitors progress of others and redirects efforts when goals are not being met.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Collaborates across boundaries, finding common ground with a wide range of stakeholders.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Is approachable and easy to talk with.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Remains calm when dealing with difficult or challenging customer situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Actively looking for ways to help customers by identifying and proposing appropriate solutions and services.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Promotes practices that are sensitive to the needs of a diverse workforce.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

20. Cultivates an active network of relationships inside and outside the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12.Accepts personal responsibility and ownership for the quality and timeliness of work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Fosters relationships by recognizing others' contribution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Demonstrates in-depth understanding and insight into customer concerns.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Is pleasant, courteous, and professional when dealing with internal or external customers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Implements effective ways to monitor, measure, and evaluate customer satisfaction.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Translates business strategies into clear objectives and tactics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Promotes practices that are sensitive to the needs of a diverse workforce.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Builds an environment where customer satisfaction (internal and external) is always a priority.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Promotes practices that are sensitive to the needs of a diverse workforce.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13.Presents a professional image and attitude, refraining from gossip.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22. Leads an inclusive workplace that maximizes the talents of each person.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Fosters an inclusive environment where people are accepting and respectful of each other.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*18. Understands and respects cultural, religious, gender and racial differences.

23. Promotes efforts to attract, develop, and retain a skilled and motivated workforce that is both diverse and inclusive.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Remains calm when dealing with difficult or challenging customer situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Implements effective ways to monitor, measure, and evaluate customer satisfaction.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*25. Understands the customer's current requirements and anticipates their future needs.

20. Demonstrates in-depth understanding and insight into customer concerns.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Builds an environment where customer satisfaction (internal and external) is always a priority.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Goes above and beyond to exceed external and internal customer expectations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*22. Diligently follows through on customer concerns to the point of resolution.

*E-Mail

What qualities, attributes or skills do you have that will contribute to your being a strong member of the Diversity Council?

Age

*Zip

Employed By/Attend School

*Part of policy?

Yes (submit to the Interdisciplinary Documentation Committee (IDC) for approval)

You may request: consultation training, as well as structural and biophysical studies.

Session 2

*Film date(s):

*Grant No: (Ex: R01 GM012345)

Attach Manuscript File(s):

(to upload multiple files, javascript must be enabled; attachments appear at end of form)

*Describe

*Email address

*What attracts you to MD Anderson's volunteer program?

*Film time(s):

Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.

*Date of Birth

Employed By/Attend School

Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.

*Please describe a business justification and any additional special considerations

Hazardous materials - Please state clearly any potential safety issues associated with the materials designated within this application.

Special Breakout Session #3: 3:40 - 5:10 pm

Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.

Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.

Are other policies/procedures impacted by/relevant to this proposed policy/procedure?

I agree that if admitted to membership, I will undertake to be governed by the By-Laws of the Council.

Building Relationships: Initiate, develop, and manage relationships and networks; show sincere interest in others and their concerns.

Country

Comments:

*Phone

Is there a particular type of volunteer position that interests you?

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Building Relationships	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23. Is trusted by others in the workgroup.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Takes the time to build credibility within the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14.Works well with others of a different background from him or herself.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

10. Adheres to the behavioral standards expected by the department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Adheres to the behavioral standards expected by the department.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Takes the time to build credibility within the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Speaks openly about tough issues facing the group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Solicits the participation of peers and direct reports in initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Seeks out relationships across the institution that are mutually beneficial.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Seeks out relationships across the institution that are mutually beneficial.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28. Is straightforward and open in dealings with counterparts in the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

11. Is trusted by others in the work group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Is straightforward and open in dealings with counterparts in the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15.Demonstrates respect to others whether in their presence or absence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Speaks openly about tough issues facing the group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Is trusted by others in the work group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Addresses conflict openly and constructively, focusing on issues rather than people.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Assumes responsibility for the outcome of his or her workgroup.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

25. Is honest in his or her dealings with others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

12. Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16.Steps forward to assist group members and other co-workers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Maintains high ethical standards and integrity.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Relates well to people regardless of their title, personality, or background.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Can be approached easily.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18. Maintains high ethical standards and integrity.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18. Addresses conflict openly and constructively, focusing on issues rather than people.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Shows consistency between words and actions.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Manages an inclusive workplace that maximizes the talents of each person.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

13. Accepts personal responsibility and ownership for the quality and timeliness of work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Shows consistency between words and actions.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Holds others accountable for achieving results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Holds self accountable for meeting commitments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17.Works with group members and co-workers to resolve problems or conflicts.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Relates well to people regardless of their title, personality, or background.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18. Accepts personal responsibility and ownership for the quality and timeliness of work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

14. Presents a professional image and attitude, refraining from gossip.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Prioritizes activities and implements practices to ensure customer needs are met.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Assumes responsibility for the outcome of his or her workgroup.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*28. Holds self accountable for meeting commitments.

20. Promotes practices that are sensitive to the needs of a diverse workforce.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Presents a professional image and attitude, refraining from gossip.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Fosters an environment that is focused on delivering quality customer service.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

20. Starts and completes work without close supervision.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Manages an inclusive workplace that maximizes the talents of each person.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Presents a professional image and attitude, refraining from gossip.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22. Understands and respects cultural, religious, gender and racial differences.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Holds others accountable for achieving results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23. Prioritizes activities and implements practices to ensure customer needs are met.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*24. Fosters an environment that is focused on delivering quality customer service.
*25. Makes the effort to understand the nature of customer issues before taking action.

Session 3

Position Held

*Specific location(s) to be filmed:

*Phone

*Shirt Size

Position Held

Contact Information at Destination

*Description of request

*Impacted or Relevant?

Yes

*Select to indicate agreement

I agree

*Date of birth

Specific description of scene(s) you intend to film (interview, b-roll, clinic appointment, etc.)

*Gender

Female

Male

*If so, tell us about it.

*Scene description:

Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.

Position Held

Technical/Functional Expertise: Demonstrate technical proficiency required to do the job; possess expertise knowledge in the profession.

*Hotel / Residence (Provide name, address, phone number)

Preliminary materials and methods to be provided by requestor. What will you provide - clones, plasmids, antibodies, reagents, etc? Do you have an established or preferred protocol that we should use?

Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.

Business Acumen: Understand the impact of the job within the Institution; use cross-functional knowledge to understand interdepartmental connections.

Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.

If yes to the previous question, list the P/P titles(s), policy numbers(s), and make necessary revisions.

Inspiring Trust: Show consistency among principles, values, and behavior; gain the confidence and trust of others.

*Email Address

*Country of citizenship or permanent residency

Thank you for taking the time to complete this form.

Business Acumen	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Business Acumen	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Technical/Functional Expertise	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Inspiring Trust	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Knows when to jump in to assist employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Works well with others of a different background from him or herself.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

20. Allocates resources (people, time and money) to achieve optimal results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

15. Works well with others of a different background from him or herself.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Speaks openly about tough issues facing the group.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18.Holds the skills and knowledge to be effective in his or her role.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Knows when to jump in to assist employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Controls costs while driving revenue generation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*18. Assumes responsibility for the outcome of his or her workgroup.

32. Efficiently coordinates group efforts to meet deadlines and outcomes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

16. Demonstrates respect to others whether in their presence or absence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19.Demonstrates technical proficiency needed to perform the job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Allocates resources (people, time and money) to achieve optimal results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Ensures financial resources are directed toward strategic initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Acts according to his or her stated values.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22. Demonstrates respect to others whether in their presence or absence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Efficiently coordinates group efforts to meet deadlines and outcomes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Acts a role model by consistently displaying a strong work ethic and professional attitude.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Acknowledges and celebrates group accomplishments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

20.Keeps skills up to the level needed to successfully complete tasks.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18. Acknowledges and celebrates group accomplishments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22. Draws accurate conclusions from financial and other quantitative information.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

17. Steps forward to assist group members and other co-workers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23. Steps forward to assist group members and other co-workers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Uses cross-organizational understanding to facilitate the needs and objectives of the organization.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28. Creates a work environment that encourages high standards.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Works with group members and co-workers to resolve problems or conflicts.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Understands how to execute the organization's business strategy to deliver the desired results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23. Identifies and uses key financial indicators necessary to measure business performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Treat others' concerns and issues with sensitivity and confidentiality.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

18. Works with group members and co-workers to resolve problems or conflicts.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Makes prudent decisions regarding significant expenditures.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

25. Shares information and expertise with other employees to enable the successful completion of the group's goals.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Assumes responsibility for the outcome of his or her workgroup.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

35. Understands the major functions of the different areas of the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*36. Ensures financial resources are directed toward strategic initiatives.

25. Remains engaged in what's going on in all areas of the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Holds self accountable for meeting commitments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Draws accurate conclusions from financial and other quantitative information.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Acts a role model by consistently displaying a strong work ethic and professional attitude.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Identifies and uses key financial indicators necessary to measure business performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*39. Makes prudent decisions regarding significant expenditures.
*40. Remains engaged in what's going on in all areas of the Institution.

If previous protein production was attempted briefly explain what steps were tried and what was the outcome. Note: Please do not provide any reagents that are irreplaceable.

Travel Safety

Education

*Patient's Name and Diagnosis

*Person or people to be filmed:

Please indicate age groups in which you have experience/interest:

P/P List

If non-US citizen, current visa status

Are you asking to film any MD Anderson patients?

For Camp Star Trails in June

Team With Others: Encourage collaboration and input from all team members; value the contributions of all members; balance individual and team goals.

If the above individual is deceased, please provide the month and year of death, the requester’s name, relation to the deceased, and email or phone number. Please note that providing your contact information will not subscribe you to any communications.

*Medical Record Number (patient or siblings MRN)

*What specific activities are of most interest to you (arts and crafts, sports, fishing, etc.)?

*Name & City of School

Communication: Express ideas clearly and concisely; listen to feedback and input carefully; acknowledge differing perspectives in a group.

Please describe all precautionary measures taken or provided by organizers to ensure your safety and health while traveling.

*Provided by requestor

Technical/Functional Expertise: Demonstrate technical proficiency required to do the job; possess up-to-date expertise knowledge in the profession; provide technical expertise to others.

Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.

Team With Others: Encourage collaboration and input from all team members; value the contributions of all team members; balance individual and team goals.

Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.

Technical/Functional Expertise: Demonstrate technical proficiency required to do the job; possess up-to-date expertise knowledge in the profession; provide technical expertise to others.

Global Perspective: Understand the position of the institution within the industry; anticipate the impact of technological, social, and economic trends on the institution.

Global Perspective: Understand the position of the Institution within the industry; anticipate the impact of technological, social, and economic trends on the Institution.

Implementation Plans

*MD Anderson patients:

Yes

*Shirt size

*Have you ever been convicted of a felony?

Yes

Business Acumen	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Technical/Functional Expertise	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Global Perspective	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Business Acumen	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Ages	6 - 8 Boy	6 - 8 Girl	9 - 10 Boy	9 - 10 Girl	11 - 12 Boy	11 - 12 Girl

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Global Perspective	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Team With Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Technical/Functional Expertise	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

20. Identifies and removes barriers to effective teamwork.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Holds the skills and knowledge to be effective in his or her role.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

19. Possesses technical and industry knowledge needed to support the institution's best interests.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Holds the skills and knowledge to be effective in his or her role.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

41. Anticipates trends and future developments in the healthcare environment.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21.Listens attentively to information or directions provided by others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Anticipates trends and future developments in the healthcare environment.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Possesses technical and industry knowledge needed to support the institution's best interests.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Identifies and removes barriers to effective teamwork.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Experience	6 - 8 Boy	6 - 8 Girl	9 - 10 Boy	9 - 10 Girl	11 - 12 Boy	11 - 12 Girl

20. Demonstrates technical proficiency required to do the job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Demonstrates technical proficiency required to do the job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22.Keeps others informed about his or her work activities.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Interest	6 - 8 Boy	6 - 8 Girl	9 - 10 Boy	9 - 10 Girl	11 - 12 Boy	11 - 12 Girl

34. Establishes a climate where all employees can contribute to their full potential.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Acknowledges and celebrates group accomplishments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Determines how best to be positioned to achieve a competitive business advantage in a global economy.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

42. Determines how best to be positioned to achieve a competitive business advantage in a global economy.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

20. Understands the general roles and responsibilities of other functional areas in the institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

35. Understands the general roles and responsibilities of other functional areas in the institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22. Involves others in shaping plans and decisions that affect them.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

35. Acknowledges and celebrates group accomplishments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Demonstrates an awareness of what impacts the organization and its success.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28. Has up-to-date knowledge in the profession and industry.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

43. Keeps abreast of global trends (e.g., technological, competitive, economic) that could impact the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

36. Demonstrates an awareness of what impacts the organization and its success.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23.Communicates clearly with others whether in writing or speaking.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

21. Quickly masters new technical knowledge necessary to do the job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28. Develops strategies to achieve and sustain competitive advantage.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Quickly masters new technical knowledge necessary to do the job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Develops strategies to achieve and sustain competitive advantage.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

36. Involves others in shaping plans and decisions that affect them.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

*If approved, HIPPA Authorizations and media releases must be obtained prior to filming.

*Physician Name

(See U.S. Department of State Guidance Website).

*Reason for request. How will you use the results?

Test an idea for an unfunded pilot project being planned.
Obtain preliminary data to support a new grant application going in soon.
Increase/accelerate the productivity of a funded project in my laboratory.
Other (Please explain briefly below)

Communication / Education Plan

Volunteer Consent

*Name & City of School

If yes, provide details including dates

Include specific information related to the local threat level, and the measures that will be in place to assure your safety.

For Camp AOK in August

Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.

DAY VOLUNTER CONSENT

Years Attended

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

*Description

If other use,

Communication: Express ideas clearly and concisely; create an environment with open channels of communication; listen to feedback and input carefully; acknowledge and listen to differing perspectives in a group.

Business Acumen: Understand the impact of the job within the institution; use cross-functional knowledge to understand interdepartmental connections.

Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.

How will the P/P be communicated to the affected constituents? [For example, Clinical Managers Forum (if house-wide P/P), Nursing Leadership or Departmental staff meeting, electronic communications, etc.]

*Video Production Company Name:

ACADEMIC HISTORY

Does the video production company have liability insurance coverage in the amount of $1 million for property damage and $2 million for injury or death?

Business Acumen	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Coach and Develop	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Coach and Develop	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Business Acumen	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Coach and Develop	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Coach and Develop	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Ages	13 - 14 Boy	13 - 14 Girl	15 - 16 Boy	15 - 16 Girl	17 -18 Boy	17 -18 Girl

22. Identifies performance issues and takes quick, corrective action to address performance gaps.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Listens to suggestions and input from others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Provides opportunities for development to employees on a regular basis.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24.Willingly accepts changes that occur in the group or institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Possesses technical and industry knowledge needed to support the institution's best interests.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Demonstrates interest in developing the careers of his or her employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Experience	13 - 14 Boy	13 - 14 Girl	15 - 16 Boy	15 - 16 Girl	17 -18 Boy	17 -18 Girl

23. Possesses technical and industry knowledge needed to support the institution's best interests.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Demonstrates interest in developing the careers of his or her employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

22. Listens to suggestions and input from others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Provides feedback to employees to let them know their efforts are appreciated.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

25.Remains open to learning new methods or procedures resulting from an institutional or a departmental change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23. Effectively balances being detailed with being concise in his or her communication.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Interest	13 - 14 Boy	13 - 14 Girl	15 - 16 Boy	15 - 16 Girl	17 -18 Boy	17 -18 Girl

46. Provides feedback to employees to let them know their efforts are appreciated.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Effectively balances being detailed with being concise in his or her communication.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Identifies performance issues and takes quick, corrective action to address performance gaps.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Understands the general roles and responsibilities of other functional areas in the institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Exerts the personal effort to understand the other business areas of the institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

23. Gives specific and constructive feedback to enhance others' development.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26.Remains calm under pressure or heavy workload.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

25. Ensures financial resources are directed toward strategic initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

39. Exerts the personal effort to understand the other business areas of the institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

47. Identifies required capabilities and skill gaps within own organizational area.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

39. Gives specific and constructive feedback to enhance others' development.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Communicates clearly with others whether in writing or speaking.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Identifies required capabilities and skill gaps within own organizational area.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Communicates clearly with others whether in writing or speaking.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

24. Willingly shares expertise and experience with others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

40. Demonstrates an awareness of what impacts the organization and its success.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Promotes sharing of expertise and a free flow of learning across the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

48. Promotes sharing of expertise and a free flow of learning across the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Understands the meaning and implications of key financial indicators.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

40. Willingly shares expertise and experience with others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27.Responds with flexibility to shifting priorities and rapid change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

49. Creates a climate in which mistakes are viewed as opportunities for learning.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28.Deals constructively with own failures and mistakes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

41. Remains aware of activities impacting budget.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*42. Ensures financial resources are directed toward strategic initiatives.
*43. Understands the meaning and implications of key financial indicators.

Diploma/Degree

Emergency Contact Information

I hereby agree to participate in the University of Texas M. D. Anderson Cancer Center’s ("Cancer Center") adolescent camp.

*CBSF Support

Check box to verify that you will acknowledge the support of CBSF.

EMERGENCY CONTACT

*Communicate P/P

*Liability insurance:

Yes

Personal Contact

*College or University (Name, Location)

Number of people in video team for on-campus filming (include any producers, videographers, photographers, etc. who will be at MD Anderson)?

What specific activities are of most interest to you (arts and crafts, sports, fishing, etc.)?

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

*Mother's/Guardian's Name

In consideration of the Cancer Center permitting myself to participate in this event, on behalf of myself, my heirs, administrators and assigns, I hereby waive and release any and all rights and claims of any nature I may have against the

Area of Concentration

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

*Full Name

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

*Target date of the communication / eduction plan

mm/dd/yyyy

Coach and Develop: Assess strengths and development needs of employees; provide challenging development opportunities; provide relevant, timely feedback; mentor others.

*Number of people:

*Dates Attended, From/To (month/year)

Coach and Develop	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self Motivation	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Coach and Develop	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Influencing Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Influencing Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Influencing Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Influencing Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29.Demonstrates a strong sense of urgency about getting the work done.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

25. Moves group toward decisions even when initial disagreement exists.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

50. Creates a climate that fosters personal investment and excellence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Assesses employees' unique development needs.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Leads by example, showing a willingness to extend him or herself to achieve results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Provides opportunities for development to employees on a regular basis.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

41. Moves group toward decisions even when initial disagreement exists.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Willingly accepts changes that occur in the group or institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

25. Willingly accepts changes that occur in the group or institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Assesses employees' unique development needs.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Knows who to involve and when.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

26. Remains calm under pressure or heavy workload.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Remains open to learning new methods or procedures resulting from an institutional or a departmental change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30.Starts and completes work without close supervision.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

42. Knows who to involve and when.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

51. Leads by example, showing a willingness to extend him or herself to achieve results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28. Develops employees through challenging assignments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Pushes the Institution to adopt new ideas and initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*35. Approaches each problem situation with a clear understanding of institutional and political reality.

43. Gains cooperation from others to accomplish goals by providing convincing information.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31.Readily puts in extra time and effort.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Gains cooperation from others to accomplish goals by providing convincing information.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

27. Responds with flexibility to shifting priorities and rapid change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

52. Helps others to see the value of what they are doing.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

35. Works effectively in ambiguous situations and demonstrates flexibility when needed.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Gives specific and constructive feedback to enhance others' development.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

46. Develops employees through challenging assignments.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*47. Gives specific and constructive feedback to enhance others' development.

28. Deals constructively with own failures and mistakes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

53. Pushes the Institution to adopt new ideas and initiatives.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

36. Gains commitment from others before implementing changes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

36. Remains calm under pressure or heavy workload.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

54. Understands the social and political dynamics within the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Responds with flexibility to shifting priorities and rapid change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

48. Set goals to aid employees in continuously raising the bar on performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Deals constructively with own failures and mistakes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

55. Navigates the political networks present within the Institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*56. Approaches each problem situation with a clear understanding of institutional and political reality.
*57. Gains commitment from others before implementing changes.

*Relationship to You

Name & City of School 2

("Cancer Center") and any organizations connected with the event, their representatives, successors and assigns for any and all injuries and damages of any nature that I may suffer while taking part in any of the activities connected with camp.

Project Purpose

Activities Interest:

Monitoring / Auditing Plan

*Major Field of Study

Describe the final video you intend to produce using the scenes filmed at MD Anderson. Include any other interviews and scenes to be filmed outside of MD Anderson.

Consent

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

In the event that I become ill or injured while attending camp, I permit the ("Cancer Center"), officials and employees to render, secure and/or authorize necessary medical treatment,

Years Attended 2

Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

*Phone Numbers (cell/work/home)

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

Is monitoring / auditing of the P/P needed for compliance?

Influencing Others: Present a compelling case for proposals and ideas; gain support and commitment from others; mobilize others to take action; negotiate persuasively.

*Video description:

Minor (if applicable)

How will the video be distributed?

Influencing Others	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self Motivation	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Providing Direction	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Providing Direction	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self Motivation	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Not At All	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Providing Direction	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Providing Direction	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Gains commitment from others in support of initiatives or ideas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32.Displays a willingness to learn new things.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

58. Actively champions initiatives to ensure successful implementation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

28. Helps others adapt to changing environments and accept new situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

39. Overcomes obstacles to achieve results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

49. Gains commitment from others in support of initiatives or ideas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Overcomes obstacles to achieve results.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Takes into account employee's concerns during a change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Actively champions initiatives to ensure successful implementation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Helps others adapt to changing environments and accept new situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

59. Assumes personal responsibility to see that change is adopted and effectively implemented.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33.Solicits developmental feedback from more experienced peers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

29. Delegates important tasks, not just tasks that he or she does not want to do.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Demonstrates a strong sense of urgency about getting the work done.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Moves the group toward decisions even when initial disagreement exists.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

50. Moves the group toward decisions even when initial disagreement exists.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Assumes personal responsibility to see that change is adopted and effectively implemented.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

40. Demonstrates a strong sense of urgency about getting the work done.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*41. Strives to meet or exceed performance goals or standards.

46. Delegates important tasks, not just tasks that he or she does not want to do.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34.Takes it upon him or herself to increase knowledge and skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

60. Balances change with continuity to continually improve.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

30. Provides direction to employees on a regular and consistent basis.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Sets high personal standards of performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

51. Knows who to involve and when.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

39. Provides direction that is consistent with organizational goals.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Knows who to involve and when.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*33. Provides compelling reasons for his or her perspective on an issue.

61. Creates a work environment where employees respond with focus toward change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

47. Provides direction to employees on a regular and consistent basis.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

52. Anticipates the positions and reactions of others accurately.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Readily puts in extra time and effort.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

31. Helps employees gain clarity about expectations for their role and job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

42. Sets high personal standards of performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

40. Provides employees the support and autonomy to carry out their work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

53. Provides compelling reasons for his or her perspective on an issue.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

41. Creates a clear, inspiring vision of the desired future state of the organization.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

43. Readily puts in extra time and effort.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

48. Helps employees gain clarity about expectations for their role and job.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

62. Provides direction that is consistent with organizational goals.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*63. Provides employees the support and autonomy to carry out their work.
*64. Does not become overly involved in operations that do not warrant this level of attention.
*65. Creates a clear, inspiring vision of the desired future state of the organization.

*Email Address

Diploma/Degree 2

and I permit the ("Cancer Center") to use the following information.

*Video distribution:

Counselor Consent

*Monitoring / Auditing

Yes

N/A (remaining questions in this section need not be completed)

*Classification as of Spring 2012 (Junior, Senior, etc.)

How will MD Anderson be described/portrayed in the video?

I hereby agree to participate in the University of Texas M. D. Anderson Cancer Center’s ("Cancer Center") adolescent camp.

*MD Anderson description:

*My health Insurance company

Area of Concentration 2

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

Providing Direction: Provide clear direction and priorities toward a common vision; clarify roles and responsibilities for employees.

If yes to the previous question, complete the following.

Secondary Contact

Who will do the monitoring?

*Expected Date of Graduation

How will the video benefit MD Anderson's mission?

Providing Direction	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Providing Direction	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

49. Encourages open discussions around important topics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

54. Considers the concerns voiced by others when implementing a change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

32. Encourages open discussions around important topics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

42. Encourages open discussion around important topics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Displays a willingness to learn new things.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Displays a willingness to learn new things.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

66. Communicates the vision of his or her workgroup to employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Helps others adapt to changing environments and accept new situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*35. Sets appropriate goals and objectives for the workgroup.

50. Keeps others informed.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

33. Listens attentively to people's ideas and concerns.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Takes it upon him or herself to increase knowledge and skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

67. Encourages open discussion around important topics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

55. Anticipates and effectively manages others' resistance to change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

43. Consistently shares information about important activities with employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Solicits developmental feedback from more experienced peers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

35. Recognizes own strengths and weaknesses.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Encourages others to express their views, even contrary ones.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

56. Helps others adapt to changing environments and accept new situations.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

36. Sensibly delegates and assigns work to employees according to their capabilities.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

34. Communicates information in a well-organized and concise manner.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

51. Listens attentively to people's ideas and concerns.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

68. Tailors communication to the audience.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

46. Takes it upon him or herself to increase knowledge and skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*47. Recognizes own strengths and weaknesses.

69. Consistently shares information about important activities with employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

57. Sets appropriate goals and objectives for the workgroup.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Clearly communicates deadlines and expectations for work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

52. Communicates information in a well-organized and concise manner.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

58. Sensibly delegates and assigns work to employees according to their capabilities.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

70. Encourages others to express their views, even contrary ones.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Provides employees the support and autonomy to carry out their work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

59. Clearly communicates deadlines and expectations for work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*60. Provides employees the support and autonomy to carry out their work.
*61. Establishes high standards of performance for employees.

*Full Name

Camp

*Policy Number

*MD Anderson's Mission:

*Overall GPA

If this request is related to an event or conference, please provide details. (Optional)

"Cancer Center" and any organizations connected with the event, their representatives, successors and assigns for any and all injuries and damages of any nature that I may suffer while taking part in any of the activities connected with camp.

Related event or conference:

*Group Number

*How did you hear about camp?

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

*Relationship to You

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

What will be monitored?

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

*Science GPA

Is there anything else you want to share about your project to help us evaluate your request? (Optional)

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Communication	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

62. Uses effective listening skills to gain clarification from others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

35. Willingly accepts changes that occur in the group or institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

71. Adapts his or her leadership style to fit the employee and situation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Adapts his or her leadership style to fit the employee and situation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

39. Encourages open discussions around important topics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

53. Willingly accepts changes that occur in the group or institution.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

36. Works constructively under stress and pressure.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

72. Provides support to direct reports that matches the needs of the situation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

63. Creates an environment that supports the open exchange of ideas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

54. Works constructively under stress and pressure.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

40. Consistently shares information about important activities with employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

46. Encourages productivity from his or her employees by understanding what motivates each one to do their best.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

73. Encourages productivity from his or her employees by understanding what motivates each one to do their best.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

41. Listens attentively to concerns expressed by others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

37. Responds with flexibility to shifting priorities and rapid change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

64. Encourages open discussions around important topics.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

55. Responds with flexibility to shifting priorities and rapid change.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

47. Commands authority when the situation calls for it.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

65. Consistently shares information about important activities with employees.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

74. Commands authority when the situation calls for it.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

66. Listens attentively to concerns expressed by others.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

*Phone Numbers (cell/work/home)

*Have you worked at a medically supervised camp or have any camp counseling experiences? If yes, where, when, and describe your role

*Name of Insured or Holder

Additional Information:

In the event that I become ill or injured while attending camp, I permit the ("Cancer Center"), officials and employees to render, secure and/or authorize necessary medical treatment,

Specify exactly what will be monitored with respect to what is acceptable.

Academic awards/honors (college)

and I permit the "Cancer Center" to use the following information.

Click on the “Submit” button below to email your completed request to Public Relations for review. (This will open a new email window with the form attached; send the email to submit.)

Please note you will be required to sign an additional form upon arrival to camp.

Foreign Language

Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.

What is the level of compliance expected?
(Ex: 90%, 100%)

*Email Address

If you have had a significant (1 semester or greater) interruption in your college studies, please provide details.

Self-Confidence	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Confidence	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Confidence	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Confidence	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*67. Solicits developmental feedback from more experienced peers.

56. Handles mistakes with poise and confidence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

38. Handles mistakes with poise and confidence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

48. Confronts problems directly in low-performance areas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

42. Regularly exerts the effort to develop new or improved skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

75. Confronts problems directly in low-performance areas.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*76. Projects self-assurance and unshakable confidence.

49. Projects self-assurance and unshakable confidence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

68. Regularly exerts the effort to develop new or improved skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

43. Understands own and others' learning needs and preferences.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

39. Tackles problems head-on and works to resolve them.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

57. Tackles problems head-on and works to resolve them.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

69. Understands own and others' learning needs and preferences.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

50. Acknowledges own limitations and leverages others' strengths to compensate for them.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

77. Acknowledges own limitations and leverages others' strengths to compensate for them.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

70. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

78. Seeks feedback to enhance performance.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

*My health Insurance company:

When will the monitoring be done?

You are encouraged to register through the US Embassy web site.

Submitting this form is not a guarantee of approval for your request to film on campus.

Background Check

Foreign Language Level

Beginner

Intermediate

Advanced

*Cell Phone

If yes, provide details

REFERENCES

*Father's/Guardian's Name

NOTIFICATION OF PERSONAL BACKGROUND CHECK

Sign Language

(Ex: Monthly, Quarterly, Spot checks, 1st month)

Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

Self Motivation: Set high standards of performance; pursue goals with energy and persistence; drive for results and achievement.

(See U.S. U.S. State Department Registration web site).

*Policy Number:

Self-Adaptability: Work in situations involving uncertainty, shifting priorities, and rapid change; deal constructively with mistakes and setbacks; demonstrate flexibility.

Two references are required in support of your application. List names, credentials, physical addresses and email addresses for individuals who will provide references on your behalf.

Self Motivation	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self Motivation	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Adaptability	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

40. Establishes clear, challenging goals with measurable outcomes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

58. Establishes clear, challenging goals with measurable outcomes.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

71. Provides support to direct reports that matches the needs of the situation.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Adjusts his or her leadership style to the situation or person.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

59. Demonstrates a strong sense of urgency about getting the work done.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

46. Encourages productivity from his or her employees by understanding what motivates each one to do their best.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

41. Demonstrates a strong sense of urgency about getting the work done.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

72. Encourages individual initiative in carrying out work.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*73. Adjusts his or her leadership style to the situation or person.

42. Strives to meet or exceed performance goals or standards.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

47. Works constructively under stress and pressure.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

60. Strives to meet or exceed performance goals or standards.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

48. Responds resourcefully to demands and challenges.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

74. Encourages productivity from his or her employees by understanding what motivates each one to do their best.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate
*75. Works constructively under stress and pressure.
*76. Responds resourcefully to demands and challenges.

*Group Number:

I hereby authorize The University of Texas Police Department or any other police agency to furnish The University of Texas Police Department any criminal history they have concerning me.

By registering, U.S. citizens make it easier for the Embassy to contact them in case of emergency.

How will the monitoring be accomplished?

Sign Language Level

Beginner

Intermediate

Advanced

*Reference 1

*Name of Insured or Holder:

I further release all agents and employees of The University of Texas M. D. Anderson Cancer Center, the person in charge of such police agency or department from all liability

Clubs/Organizations Skill

(Ex: Ongoing Medical Record Audits, special audit, other)

Note: if you are not a U.S. citizen, you are encouraged to look into registering with the Embassy of your citizenship.

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.

Develop Oneself: Pursue learning and self-development; actively seek feedback; transfer learning into next steps.

Self-Confidence: Recognize own knowledge, skills, and abilities; respond to challenging situations with confidence; understand limits in self.

NOTE: Within 3 months of the P/P's implementation, you will be asked to produce reports regarding the P/P's implementation efforts, which will be sent to the Policy Governor, so keep track of your monitoring and auditing with reports.

*Reference 2

Self-Confidence	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Self-Confidence	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Develop Oneself	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

49. Handles mistakes with poise and confidence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

43. Recognizes own strengths and weaknesses.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

77. Handles mistakes with poise and confidence.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

61. Solicits developmental feedback from more experienced peers.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

44. Regularly exerts the effort to develop new or improved skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

62. Recognizes own strengths and weaknesses.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

50. Makes positive changes to behavior in response to feedback.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

78. Makes positive changes to behavior in response to feedback.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

63. Regularly exerts the effort to develop new or improved skills.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

45. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

64. Actively promotes the workplace as a learning environment that encourages employees to learn from each other.	Not At All	Some Extent	Great Extent	Very Great Extent	Cannot Rate

Policy/Procedure Document

Clubs/Organization Skill Level

Beginner

Intermediate

Advanced

resulting from the furnishing of this information to The University of Texas M. D. Anderson Cancer Center.

Please note you will be required to sign an additional form upon arrival to camp.

Acknowledgements

*Indicate how you know these individuals and why they have been selected to provide a reference for you.

LEVEL OF ASSISTANCE FOR YOUR CHILD

Background Check

Registration with the International SOS is required either by booking travel with MD Anderson contracted agency, Corporate Travel Planners, or by manually enrolling in International SOS prior to my departure.

Please indicate age groups in which you have experience/interest:

I understand that the criminal history information request shall be handled by the Chief of Police of The University of Texas M. D. Anderson Cancer Center who shall be responsible for the confidentiality of such information.

Provide information of 2 people who may be contacted for questions regarding the P/P.

NOTIFICATION OF PERSONAL BACKGROUND CHECK

(To learn more about the services available to University of Texas employees, visit the International SOS and enter the membership number for UT System - 11BSGC000037.)

For Camp Star Trails in June

Only the University of Texas M. D. Anderson Cancer Center Police Department will have access to the files. and neither I, nor any other individual except by court order, will be allowed to see the information in these files for any reason.

*Contact Name

Ages	6 - 8 Boy	6 - 8 Girl	9 - 10 Boy	9 - 10 Girl	11 - 12 Boy	11 - 12 Girl
Experience
Interest

Cell Phone

I understand that if after review of the information, the Chief of Police determines that I represent a risk to the Institution; I will be deemed unsuitable for the position and will be separated or removed from consideration.

*International SOS

I certify that I will register with the International SOS

I hereby authorize The University of Texas Police Department or any other police agency to furnish The University of Texas Police Department any criminal history they have concerning me.

Level	Independent	Close Supervision	Moderate Assistance	Total Care
*Daily Care (brushing teeth, combing hair, dressing)
*Meals
*Bathing/Showering
*Toileting/Bathroom

*Contact Phone

I further release all agents and employees of The University of Texas M. D. Anderson Cancer Center, the person in charge of such police agency or department from all liability

(See U.S. Department of State International Travel Safety guidelines)

*Applicant's Name

For Camp AOK in August

If both parents/guardian should leave home for any extended length of time while their child attends Camp, you must advise the camp where you can be contacted in case of emergency.

*Contact Name

Ages	13 - 14 Boy	13 - 14 Girl	15 - 16 Boy	15 - 16 Girl	17 - 18 Boy	17 - 18 Girl
Experience
Interest

*Travel Safety guidelines

I certify that I have reviewed the U.S. Department of State International Travel Safety guidelines

EMERGENCY CONTACT (IF PARENT OR GUARDIAN CANNOT BE REACHED

resulting from the furnishing of this information to The University of Texas M. D. Anderson Cancer Center.

Other

This date is a requirement of the Department of Public Safety and will be used only for the purpose of a criminal history inquiry.

Food Allergies or special dietary requirements

*Contact Phone

Additional Medical Concerns

Other

HEALTH QUESTIONAIRE

*Describe how this program will help you achieve your career goals

Cell Phone

In case of an emergency, please notify:

Is there anything else you want us to know about you, your goals or ideas for yourself at camp?

Dose

About you:

How Given

First Name

Due to the number of applications and limited number of spaces a waiting list will be established in order of priority. Children on active treatment and their siblings will be highest priority.

RESEARCH

*Have you ever had any license, certificate or employment suspended, revoked, terminated or adversely affected?

Yes

*Last Name

Please call (713) 792-3362 for more information. Or email: camps@mdanderson.org

Frequency

If selected, you will perform research sponsored by CPRIT within the laboratory of an assigned faculty mentor at the University of Texas, MD Anderson Cancer Center.

Authorization

If yes to above, provide a full description including dates and circumstances:

*Relationship

Reason

In order to match your interests with available mentors, please attach a description of any past research experience, specific areas of research interest and particular situations that led to this interest.

*Have you been previously convicted of a felony or misdemeanor?

Yes

*Home Phone

I certify that, to the best of my ability, all information is true and up-to-date:

The format for this description is:
Double-spaced
Font: Arial or Helvetica
Size: 12pt or greater
Length: 500 words or less

Drug Name and Strength

Agreement

*Signature

I agree

Dose

APPLICANT'S CERTIFICATION AND AGREEMENT
Please Read Carefully

Physician's Name

I hereby authorize The University of Texas M. D. Anderson Cancer Center to obtain information pertaining to any charges or convictions I may have for federal and state criminal law violations.

How Given

If a patient at M.D. Anderson, identify your:

Frequency

This information will include but not be limited to allegations and convictions committed upon minors,

Center Station:

Reason

Name of Doctor:

and will be gathered from any law enforcement agency of this state or any other state or federal government to the extent permitted by state and federal law.

SUPPORTING DOCUMENTATION

I also authorize all persons, public agencies, courts, schools, employer companies, and corporations to supply verification of the information provided in my application

Phone

Drug Name and Strength

This application must be accompanied by

Current college transcript (may be attached or sent separately)
Two letters of reference (may be attached or sent separately)
Description of Research Experience and Interest (attach below)

*1. Have you had any serious health problem that would keep you from volunteering?

Yes

as well as evaluation of my prior performances, and I release them from all liability from their doing so.

Dose

Attach file

(to upload multiple files, javascript must be enabled; attachments appear at end of form)

How Given

If yes to above, please describe:

The above statements are true and complete to the best of my knowledge.

Frequency

SUBMIT APPLICATION

All materials must be received by December 31, 2011. It is the applicant's responsibility to ensure that the application and supporting documentation (letters, transcripts) is submitted on time.

*2. Date of last physical examination:

mm/dd/yyyy

Reason

Upon the offer of a Counselor position, I understand that I must supply the camp with insurance verification.

Supplemental Nutrition

Intravenous (IV): Intramuscular (IM); Subcutaneous Medications (SQ):

Any falsification, misrepresentation, or incompleteness in this disclosure is alone grounds for disqualification. The information that I have provided may be verified, in necessary, by contacting persons or organizations named in this application.

Physical examination results:

3. Immunizations:

*Have you been previously convicted of any crime related to the abuse, mistreatment, or molestation of children?

Yes

Letters of reference and current college transcript may be submitted via email to: gradschool@mdanderson.org

If yes to above, provide a full description including convictions, dates, and circumstances:

Drug Name and Strength

*H1N1 Flu Vaccine

Yes

Please include your name in the subject line of emails submitted to gradschool@mdanderson.org. Late applications or applications that do not follow the guidelines will not be considered.

Authorization

I certify that, to the best of my ability, all information is true and up-to-date:

*Applicant's Name.

I certify that, to the best of my ability, all information is true and up-to-date:

*Signature

I agree

*Signature

I agree

This date is a requirement of the Department of Public Safety and will be used only for the purpose of a criminal history inquiry.

*Legal guardian's fullname:

*Relationship to the camper

*Applicant's Date of Birth

mm/dd/yyyy

If under 18 years of age:

*Sex:

Male

Female

I certify that, to the best of my ability, all information is true and up-to-date.

Legal guardian's full name:

*Race/Ethnic Category:

White (Not of Hispanic Origin) - Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East

Black (Not of Hispanic Origin) - Persons having origins in any of the Black racial groups of Africa.

Hispanic - Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

Asian or Pacific Islander - Persons having origins in any of the original peoples of the Far East. Southeast Asia. the Indian Subcontinent, or the Pacific Islands

American Indian or Alaskan Native - Persons having origins in any of the original peoples of North America

Authorization

I certify that, to the best of my ability, all information is true and up-to-date:

*Signature

I agree

If under 18 years of age:

I certify that, to the best of my ability, all information is true and up-to-date.

home

*First Name:

Full Name

*Name

*Camp

*First Name:

*Camp:

Limit contact

*Name

*Request ID

*Full Name

Employee Email

*Employee ID

*Name

*Name

*First Name:

Author/Initiator

*Name

*Author/Initiator

*Author/Initiator

*Your Name

*First Name

*Name

*Name

*Due Date

*Due Date

*Camp

*Child's First Name

*Project Name

Email

*Project Name

*Due Date

*Last Name:

*Feedback

*Project Name

*Child's Last Name

*First Name

*Title:

*Camp

MRN #

*I would like more information on these topics

*I would like to nominate[name and department]

*I would like more information on these topics

*Phone

*Phone

*First Name

*Last Name

*First Name

*Will your child ride the bus to the campsite?

*First Name

*Department

*Will your child ride the bus from camp back to the hospital?

*Last Name

*Email

*Department:

*First Name

*Department

*Phone

*Email:

*Email

*Phone No:

*First Name

*Child's First Name

*Name

*Last Name

*PMID:

*Phone

Name (Optional):

*First Name

*First Name

*Child's Last Name

Fax

*First Name

*Phone

*First Name

*Last Name:

Do not contact me by:

*Name

*School/Organization

*Request Date

*I would like to nominate
[name and department]

*Full Name
as it appears on passport