Please provide as much information as possible.
* Indicates a required field. |
|
|
|
|
First Name:*
|
Middle Name:
|
Last Name:*
|
E-mail Address:*
|
Address:*
|
City:*
|
State:*
|
Zip code:*
|
Mobile/Primary Phone:*
|
Alternate Phone:
|
1. How did you hear about our program?
(If referred by a current SP, please list their name):*
|
2. Do you know any UCSD medical students?*
Yes
No
|
3. Do you currently work for UCSD?*
Yes
No
|
4. Have you ever worked as an SP before?*
Yes
No
|
If yes, at what program or university and when?
|
5. Do you have any acting or teaching experience?*
Yes
No
|
If yes, please give more information.
|
6. Languages spoken (other than English)
|
7. Are you 18 years or older?*
Yes
No
|
8. Are you authorized to work in the U.S.?*
Yes
No
|
9a. Our students may conduct a focused physical exam on you. You
will be required to dress in a hospital gown wearing only your undergarments. Students are NOT allowed to do pelvic, rectal, genital or breast (female) exams.
Are you comfortable with this?*
Yes
No
|
9b. Women Only: Would you be willing to be considered for roles which require you to be braless?
Yes
No
|
10. Do you have any scars, tattoos, and/or birthmarks?*
Yes
No
|
If yes, please specify:
|
11. Have you had any chronic medical conditions or past surgeries?*
Yes
No
|
If yes, please specify:
|
The following information is OPTIONAL, but would help us match you to specific patient roles: |
Date of Birth (mm/dd/yyyy):
|
Gender
Male
Female
|
Ethnicity:
|
Height:
|
Weight:
|
|
