Name *

First Name

Last Name

Phone *

(###)

###

####

Are you an enrolled student at the Medical University of South Carolina? *

Yes

No

Are you fluent in any languages besides english? *

Yes

No

Have you completed a PHR Approved training? *

Yes

No

What was the date of the training?

MM

DD

YYYY

Are there any types of evaluation that you DO NOT feel comfortable being a part of?

GYN

Peds

Rape

Domestic Abuse

Other (please specify at the end of the form)

Besides performing cases, are there any other areas of our clinic you are interested in working in?

Advocacy

PR

Event Planning

Research

Other (please describe at end of form)