ࡱ> #` bjbj5G5G ?W-W-XJ)J)J)8)~* D4.,h11111x4lz5CCCCCCC$=EhG~BC26112626BC11C:::26X11C:26C:::1", J)6:<C0 D:#H 7#H:#H:D2626:2626262626BCBC(:262626 D26262626## FIRST & LAST NAME FORMTEXT      TODAY S DATE: FORMTEXT      EMAIL ADDRESS FORMTEXT      ARE YOU 18 YEARS OR OLDER? Yes  FORMCHECKBOX  No  FORMCHECKBOX SOCIAL SECURITY # FORMTEXT    - FORMTEXT   - FORMTEXT     HAVE YOU APPLIED TO THIS PROGRAM BEFORE? Yes  FORMCHECKBOX  No  FORMCHECKBOX ADDRESS (local) : FORMTEXT       FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      NUMBER & STREET CITY, STATE, ZIP CODEPHONE NUMBERS: HOME( FORMTEXT    ) FORMTEXT    - FORMTEXT     CELL( FORMTEXT    ) FORMTEXT    - FORMTEXT     OTHER (Work)( FORMTEXT    ) FORMTEXT    - FORMTEXT     ADDRESS (permanent) : FORMTEXT       FORMTEXT      ,  FORMTEXT      ,  FORMTEXT       NUMBER & STREET CITY, STATE, ZIP CODEIN CASE OF EMERGENCY, CONTACTNAME: FORMTEXT      RELATIONSHIP: FORMTEXT      ADDRESS: FORMTEXT       FORMTEXT      ,  FORMTEXT      ,  FORMTEXT      NUMBER & STREET CITY, STATE, ZIP CODE PHONE NUMBERS: HOME( FORMTEXT    ) FORMTEXT    - FORMTEXT     CELL( FORMTEXT    ) FORMTEXT    - FORMTEXT     OTHER (Work)( FORMTEXT    ) FORMTEXT    - FORMTEXT      ARE YOU FLUENT IN ENGLISH? Yes  FORMCHECKBOX  No  FORMCHECKBOX ADDITIONAL LANGUAGES SPOKEN: (other than English) FORMTEXT      FLUENCY LEVEL:  FORMCHECKBOX MODERATE FORMCHECKBOX FLUENT FORMCHECKBOX BEGINNER FORMTEXT      FLUENCY LEVEL:  FORMCHECKBOX MODERATE FORMCHECKBOX FLUENT FORMCHECKBOX BEGINNER FORMTEXT      FLUENCY LEVEL:  FORMCHECKBOX MODERATE FORMCHECKBOX FLUENT FORMCHECKBOX BEGINNERCOLLEGE OR UNIVERSITY ATTENDING: FORMTEXT      YEAR IN SCHOOL: FORMTEXT      MAJOR & DEGREE EXPECTED: (ex. Biology, Chemistry, English) FORMTEXT      CUM G.P.A. 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layt24$Ifkkd8$$Ifl>++ t0+44 layt24!kkd<$$Ifl>++ t0+44 layt24$IfCDE]^lmnxy!"#-.qcMqKU*j%>ht hxN5OJQJU^Jht hxN5OJQJ^J$jht hxN5OJQJU^Jht hxNOJQJ^J/ju<h9Bqh;CJOJQJU^JaJ/j<h9Bqh;CJOJQJU^JaJ ht hxNCJOJQJ^JaJ)jht hxNCJOJQJU^JaJ/j;h9Bqh;CJOJQJU^JaJ!" kkd>$$Ifl>++ t0+44 layt24 $IfgdCQ.kkd=$$Ifl>++ t0+44 layt24     Have you ever been convicted of a felony?YES  FORMCHECKBOX  NO  FORMCHECKBOX (If you answered yes, please explain below): FORMTEXT      Do you use, even on an occasional basis, any illicit drugs or controlled substances without a doctor s prescription, including, but not limited to, marijuana?YES  FORMCHECKBOX  NO  FORMCHECKBOX (If you answered yes, please explain below): FORMTEXT      I certify that all of the information I have supplied in this application is true and accurate to the best of my knowledge. I understand that falsification of the information on this form is grounds for immediate termination from the Clinical Care Extender Program. FORMTEXT       FORMTEXT      APPLICANT S SIGNATUREDATE Please tell us how you heard about the Clinical Care Extender Program.  FORMCHECKBOX Internet __________________________  FORMCHECKBOX College Organization: FORMTEXT       FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Current Intern (Name): FORMTEXT      What do you think are the most important characteristics and attributes a person must possess to be successful in patient care? How do you rate yourself in these areas? Please write a well developed essay in the limited space provided. FORMTEXT       As a Clinical Care Extender you will be expected to work independently at times. Do you consider yourself to be assertive and self-sufficient? If so, explain why and give examples. Please write a well developed essay in the limited space provided. FORMTEXT       What would you most like to accomplish as a Clinical Care Extender and how does the program fit your overall goals? Please write a well developed essay in the limited space provided. 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