Student Submission Form

    First Name*

    Last Name*

    Address 1*

    Address 2

    City*

    State*

    Zip/Postal Code*

    Phone (Home/Cell)*

    Phone (Work)*

    Email*

    Date Of Birth*

    Sex*

    MF

    Do you have an EPIC User ID?*

    YN

    If YES, what is your ID?

    EDUCATION

    What is your highest level of education completed? *

    High SchoolGEDCollege

    Course Of Study

    Other Formal Education and/or Training

    Professional Certifcations

    PERSONAL INFORMATION

    Have You Ever Been Convicted Of A Crime and/or Incarcerated? *

    YN

    If YES, Please Explain:

    Amount Of Time Requesting Per Week: *

    Name Of Instructor For Work Student Experience *

    Instructor's Phone *

    Instructor's Address

    Do You Speak Any Languages Other Than English?

    YN

    If YES, which Language?

    If YES, which describes your level?

    PERSONAL EMERGENCY CONTACT

    Name*

    Relationship*

    Address 1*

    Address 2

    City*

    State*

    Zip/Postal Code*

    Emergency Contact Phone (Home/Cell)*

    Emergency Contact Phone (Work)*

    STATEMENT OF AGREEMENT

    I am interested in a student experience with ECHC. I am prepared to receive training and
    to devote the agreed- upon time for this purpose. I will hold ECHC blameless if I incur injury
    and/or incident as a student.

    As a student, I understand ECHC requires that I sign a confidentiality statement and may
    need to be immunized, depending on the placement(s) assigned. I understand and agree that I am
    not entitled to payment for the training activities conducted at ECHC during this school-required
    experience. I also understand and agree that there is no expectation of a job at ECHC during or at
    the end of this training experience.

    All information in this application form is complete and accurate.

    If you agree with this statement, please type your full name. *

    Today's Date *