https://form.jotform.com/260534612892055

1
Full Legal Name* This field is required.
First Name
Last Name
2
Preferred Name
3
Email* This field is required.
example@example.com
4
Phone (Primary)* This field is required.
Please enter a valid phone number.
5
Phone (Alternate)
Please enter a valid phone number.
6
Best Contact Method* This field is required.
Text
Call
Email
7
Additional Charisma SPD Internship/Clinical Service SMS Consent (Optional) — I agree to receive text messages from Charisma SPD Certification & Staffing about my internship or clinical application, placement and site-assignment updates, scheduling, document and medical-clearance reminders, hour-completion reminders, and support. Message frequency varies. Msg & data rates may apply. Reply STOP to cancel; HELP for help. Consent is optional, is not a condition of submitting this form, purchasing services, or receiving an internship placement, and I can submit without consenting.
I agree to receive text messages
I do not agree
8
Charisma SPD Internship/Clinical Service SMS Consent (Optional) — I agree to receive text messages from Charisma SPD Certification & Staffing about my internship or clinical application, placement and site-assignment updates, scheduling, document and medical-clearance reminders, hour-completion reminders, and support. Message frequency varies. Msg & data rates may apply. Reply STOP to cancel; HELP for help. Consent is optional, is not a condition of submitting this form, purchasing services, or receiving an internship placement, and I can submit without consenting.
I agree
9
Charisma SPD Promotional/Marketing SMS Consent (Optional) — I agree to receive promotional and marketing text messages from Charisma SPD Certification & Staffing about training programs, internships, staffing opportunities, events, and offers. Message frequency varies. Msg & data rates may apply. Reply STOP to cancel; HELP for help. This consent is optional, separate from service-message consent and all program acknowledgments, and is not a condition of submitting this form, purchasing services, or receiving an internship placement. I can submit without consenting.
I agree
10
Home Address* This field is required.
Street Address
Apartment / Unit
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Date of Birth* This field is required.
Date
Month
Day
Year
12
I confirm I am at least 18 years old* This field is required.
I confirm I am at least 18 years old
13
Emergency Contact Full Name* This field is required.
First Name
Last Name
14
Emergency Contact Relationship* This field is required.
15
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
16
Government-issued ID type* This field is required.
Driver’s License / State ID
Passport
Other
17
Government ID Number* This field is required.
18
Upload Government ID (Front)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
19
Upload Social Security Card (Photo or Scan)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
20
Upload a Selfie / Photo for Verification* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
21
Are you currently enrolled in Charisma SPD training?* This field is required.
Yes
No
22
If no, please indicate the school/training center where you were trained.* This field is required.
23
Availability days* This field is required.
Mon
Tue
Wed
Thu
Fri
Sat
Sun
24
Preferred shift(s)* This field is required.
Days
Evenings
Flex Shift (Between day and Evening)
25
Medical Form* This field is required.
I will schedule appointment to have my medical done as soon as possible
I have had medical done not longer that a year and would need a Physician to validate to submit
I have already submitted my medicals
26
Upload Medical Documentation
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
27
Earliest start date* This field is required.
Date
Month
Day
Year
28
Preferred facility (select all that apply)* This field is required.
Lincoln Hospital
NYU Medical Center
Harlem Hospital
Westchester Medical Center
Other
29
HSPA Certification Exam Status* This field is required.
Please Select
Please Select
Not scheduled
Scheduled
Passed
Failed
Not applicable
30
Upload Proof of Certifications
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
31
Charisma SPD internships/clinical rotations must be completed within 3 months (90 days) from the confirmed start date unless an extension is approved in writing.
32
I understand the internship/clinical rotation must be completed within 3 months (90 days) from the confirmed start date unless an extension is approved in writing.* This field is required.
I Understand
33
I understand that I may be removed from the Charisma SPD program and/or clinical placement at any time if I fail to comply with hospital policies and procedures and/or Charisma SPD policies, standards, and expectations.* This field is required.
34
Signature (Program Conduct Acknowledgment)* This field is required.
Should be Empty: