CLINICAL CARE EXTENDER PIPELINE
Application
Section 1: Personal Information

FIRST NAME

MIDDLE NAME

LAST NAME

How did you hear about the Clinical Care Extender Pipeline?
PLEASE SPECIFY

Have you applied to the Clinical Care Extender Pipeline before?
Were you previously a Clinical Care Extender?
Are you 18 years or older?
Please check here if you are interested in the accelerated track to receive a secondary application
PERMANENT ADDRESS:
STREET

HOME PHONE

CITY

CELL PHONE

STATE

WORK PHONE

E-MAIL

ZIP CODE

OTHER PHONE

ALTERNATE E-MAIL

**Only Gmail or Yahoo email addresses will be accepted

Section 2: Emergency Contact Information
EMERGENCY CONTACT:
NAME

EMERGENCY CONTACT
ADDRESS:

RELATIONSHIP

STREET

HOME PHONE

STATE

CELL PHONE

CITY

ZIP CODE

WORK PHONE

Section 3: Education and Previous Experience

MOST RECENT COLLEGE/UNIVERSITY

GRADUATED?

MAJOR/DEGREE

YEAR IN SCHOOL

CUM GPA

OTHER COLLEGE/UNIVERSITY

GRADUATED?

MAJOR/DEGREE

YEAR IN SCHOOL

CUM GPA

HIGH SCHOOL

GRADUATED?

MAJOR/DEGREE

YEAR IN SCHOOL

CUM GPA

CURRENT CAREER GOAL

ALTERNATE CAREER GOAL

PLEASE LIST WHERE YOU WORK (if applicable):
ADDITIONAL LANGUAGES:
(Besides English)
LANGUAGE 1

FLUENCY

LANGUAGE 3

FLUENCY

LANGUAGE 2

FLUENCY

LANGUAGE 4

FLUENCY

Section 4: Applicant Certification
* Please read the following statement in its entirety, and type your name on the signature line below to verify your agreement to the terms:

By my signature below, I certify the information provided above, and any other information in connection with this application form, including the written essay responses, is true, accurate, and completed by myself, the applicant. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for all background reports requested by or on behalf of COPE Health Solutions and/or my desired hospital volunteer site. I understand that I will be required to submit to a background check and that all parts of the background report must comply with the guidelines set forth by my desired volunteer hospital site in order to fulfill the requirements for the Clinical Care Extender Internship.

APPLICANT SIGNATURE

DATE

CLINICAL CARE