Application Form

If you are interested in applying to become a standardized patient, please complete this on-line form, and we will contact you within 10 business days to schedule an interview. This information is kept confidential, and is used to help us keep in touch with you as opportunities arise.

Name:
Address :
Home Phone:
Work Phone:
Email:
Age:
Are you a full time state or UNC employee?	Yes No
Are you a part time state or UNC employee?	Yes No If so, how many hours do you work?
Do you have any experience acting, teaching, or working in a health care field?	Yes No
If yes, please describe:
Given your schedule, what times of day would you be available to work? (please check all that apply)	Mornings: Afternoons: Evenings: Saturdays:
When you have completed the form, please click the submit button to send your information to the Standardized Patient Coordinator, Erica Clarkson. You may also contact Ms. Clarkson by phone at 919-843-9372. If you would like to clear this form and start over, please click the clear button and continue. Thank you again for your interest in our program.