HEALTH CARE TALENT INNOVATIONS

APPLICATION
SECTION 1: PERSONAL INFORMATION
FIRST NAME MIDDLE NAME STREET HOME PHONE CELL PHONE CITY WORK PHONE LAST NAME STATE OTHER PHONE ZIP CODE

PERMANENT ADDRESS:

E-MAIL
**Only Gmail or Yahoo e-mail addresses will be accepted

ALTERNATE E-MAIL

Please indicate the internship site you are applying to:

**You may only apply to one site

How did you hear about us? Have you applied to this internship before? Were you previously a Clinical Care Extender? Are you 18 years or older? Are you interested in the accelerated track? If applicable, please mark one or more of our other Internship site(s) at which you would consider interning (check all that apply): Glendale Adventist Medical Center (Glendale) Citrus Valley Health Partners (West Covina, Covina, Glendora) Hoag Memorial Hospital Presbyterian (Newport Beach, Irvine) Riverside Community Hospital (Riverside) St. Francis Medical Center (Lynwood) St. John's Hospitals (Oxnard, Camarillo) St. Mary Medical Center (Long Beach)
PLEASE SPECIFY

SECTION 2: EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT:
NAME RELATIONSHIP

EMERGENCY CONTACT ADDRESS:

HOME PHONE

STREET CELL PHONE

STATE

CITY WORK PHONE

ZIP CODE

SECTION 3: EDUCATION AND PREVIOUS EXPERIENCE

MOST RECENT COLLEGE/UNIVERSITY OTHER COLLEGE/UNIVERSITY HIGH SCHOOL CURRENT CAREER GOAL GRADUATED? GRADUATED? GRADUATED? MAJOR/DEGREE MAJOR/DEGREE MAJOR/DEGREE YEAR IN SCHOOL YEAR IN SCHOOL YEAR IN SCHOOL CUM GPA CUM GPA CUM GPA

ALTERNATE CAREER GOAL

PLEASE LIST WHERE YOU WORK (if applicable): ADDITIONAL LANGUAGES: LANGUAGE 1 (Besides English)
LANGUAGE 2

FLUENCY FLUENCY

LANGUAGE 3 LANGUAGE 4

FLUENCY FLUENCY

SECTION 4: APPLICANT CERTIFICATION

* Please read the following statement in its entirety, and type your name on the signature line below to verify your agreement to the terms

By my signature below, I certify the information provided above, and any other information in connection with this application form, including the written essay responses, is true, accurate, and completed by myself, the applicant. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for all background reports requested by or on behalf of COPE Health Solutions and/or my desired hospital volunteer site. I understand that I will be required to submit to a background check and that all parts of the background report must comply with the guidelines set forth by my desired volunteer hospital site in order to fulfill the requirements for the Clinical Care Extender Internship.

APPLICANT SIGNATURE

DATE

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HEALTH CARE TALENT INNOVATIONS

APPLICATION
SECTION 5: PROMPT RESPONSES
1. DESCRIBE PRIOR COMMUNITY SERVICE, EXTRACURRICULAR ACTIVITIES, AND LEADERSHIP EXPERIENCE.

(Please type your response in the box below. 1500 character limit)

2. EVALUATE A SIGNIFICANT EXPERIENCE, ACHIEVEMENT, OR RISK THAT YOU HAVE TAKEN AND ITS IMPACT ON YOU.

(Please type your response in the box below. 1500 character limit)

3. HOW DOES THE CLINICAL CARE EXTENDER INTERNSHIP FIT INTO YOUR OVERALL CAREER GOAL?

(Please type your response in the box below. 1500 character limit)

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HEALTH CARE TALENT INNOVATIONS

APPLICATION
SECTION 5 (continued): PROMPT RESPONSES
4. HOW WOULD YOU DEFINE THE CORE VALUES OF THIS INTERNSHIP AND IF ACCEPTED, HOW WOULD YOU UPHOLD THESE VALUES?

(Please type your response in the box below. 1500 character limit)

5. HOW WOULD YOU UTILIZE YOUR ROLE AS A CLINICAL CARE EXTENDER TO IMPROVE THE PATIENT EXPERIENCE IN A HOSPITAL?

(Please type your response in the box below. 1500 character limit)

6. IT IS OFTEN SAID THAT WHAT YOU PUT INTO THIS INTERNSHIP IS WHAT YOU GET OUT. WHAT DO YOU PLAN ON INVESTING IN THIS INTERNSHIP AND HOW WILL YOU FOLLOW THROUGH WITH YOUR INITIAL GOALS?

(Please type your response in the box below. 1500 character limit)

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