Standardized Patient Application

Standardized Patient Application

Clinical Skills and Simulation Center - Glendale Campus
Full Legal Name
Preferred Name
Preferred Pronouns
Birth Date

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (mobile # preferred)*
Email Address*
example@example.com
How did you hear about SP work at Midwestern University ?
Are you currently a student or employee of Midwestern University ?

YesNo
Are you currently in school ?

YesNo
If yes, please explain.
What is your highest level of education ?
Please indicate institution and degree/major
Do you have any special training/experience ? (i.e. performing arts, teaching, volunteer work, etc)
Disclaimer

Providing the demographic information below does not prohibit the applicant from employment. This information is strictly used to identify demographic fit for hiring sessions.
Height
Weight
Gender at birth

MaleFemaleOther
Surgical Scars/Absent Organs
Physical Limitations (NOTE: this is for demographic purposes only)
What languages do you speak and what is your fluency level ?
Do you have any experience as a Standardized Patient ?

YesNo
Please describe and include location(s)
Please indicate any days of the week (M-F) when you do NOT have availability
Our usual operational hours are 7:30am - 6:00pm. Please indicate any times when you have CONSISTENT LIMITATIONS in availability during this time range.
Why are you interested in working as an SP?
Tell us about yourself
Please provide name, relationship, phone, and email address of at least TWO references
OPTIONAL: If you would like to submit a current resume and/or headshot, please do so below

Cancelof
Should be Empty:

Standardized Patient Application

Disclaimer