SALT Academy Intake Form

SALT Academy Intake Form
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2 : General Information

Personal Information section. Provide your basica contact details so we can set up your Academy profile .
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3 : - Role Selection
StudentInternVolunteerFaculty / StaffContractorOther ( specify _
Program or Position Details

Tell us more about your academic program or the role you will be serving in .
Field 1 : School or Department
Field 2 : Program , Major , or Position Title
Field 3 : Expected Graduation or Start Date

MonthDayYear
Date
Field 5 - Availability

Let us know the days and times you are generally available
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Field 2 ; Hours Available Examples 9am - 2 pm
Field 3 : Preferred Start Date

MonthDayYear
Date
Field 6 - Emergency Cotact

Provide the information of someone we can contact in case of an emergency
Field 1 : Emergency Contact Name
example@example.com
Field 2 : Relationship
Field 7 - Policy Acknowledgement

Please review and acknowledge the basic policie required for participation in the Academy
I will follow the Academy's Code of Conduct .I understand that attendance and participaiton are required .I agree to maintain confidentiality when appropiate.I agree to complete all required digital training modules.I understand that communication will be sent to the email I provided
Field 8 - Signature

Please sign below to confirm that the informaiton you provided is accurate to the best of your knowledge .
Signature
Field 9 Date Signed

MonthDayYear
Date
Should be Empty:

SALT Academy Intake Form

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2 : General Information

3 : - Role Selection

Program or Position Details

Field 5 - Availability

Field 6 - Emergency Cotact

Field 7 - Policy Acknowledgement

Field 8 - Signature