Standardized Patient Application

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Standardized Patient Application

Name*

Email*

Phone Number - most easily reached*

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Street Address*

State*

City*

Zip Code*

Date of Birth*

Gender*

Male
Female

Ethnicity*

Height (EX: 5'10)*

Weight*

Are you 18 years or older?*

Yes
No

Are you authorized to work in the U.S.?*

Yes
No

Emergency Contact Name*

Emergency Contact Number*

Relationship to Emergency Contact*

Please note, answering no to the questions below does not automatically exclude you from participating as an SP.

How did you learn about our SP program? If it is a specific person, please list by name.*

Why would you like to be an SP?*

Do you know or are you related to any Wake Forest School of Medicine MD, CRNA, or PA students?*

Yes
No

Are you currently employed by WFBH, WFSOM, or any of its affiliates?*

Yes
No

Have you previously been employed by WFBH, WFSOM, or any of its affiliates?*

Yes
No

Do you speak another language? "other than English fluently." If so, please list here.*

Which campus would you be willing to work?*

Winston-Salem, NC
Boone, NC
Both (Winston-Salem, NC & Boone, NC)

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