Cardiac/Pulmonary Rehab and The Summit Medical Fitness Center Student Application

Please fill out this application completely to be considered.

Last Name *

First Name *

Middle Initial

Today's Date *

Mailing Address *

City *

State *


Zip Code *

Phone # *

Cell Phone Number *

Email address *

Emergency contact *

Emergency contact phone # *

Upload a current CV or resume. *


Have you ever been convicted of a felony? *
Yes   No  

If yes, explain. If not enter N/A *

Is this required by the college for your program? *
Yes   No    

Upload your Course Objectives here *


College Currently Attending for this request *

College Address *

Instructor name *

Instructor phone or email address *

Student request for which semester/quarter? *
Winter   Spring   Summer   Fall  

Name of program: *

Goal Start Date *

Goal End Date *

How many hours are required/needed? *

Year requesting. *
2020   2021   2022   2023   2024   2025  

Additional College Education

Additional College Address

Additional College From

Additional College To

Did you graduate from an Additional College?
Yes   No  

Degree Received from Additional College

Additional College Instructor Phone or email address

Please provide at least two references to be considered. Please provide the following for each reference: Name, Relationship, Company, Phone and email or physical address *

Are you currently employed? *
Yes   No  

If so, please provide the Company Name. If not, please enter N/A. *

Company Phone

Company Address

Supervisor

Job Title

Responsibilites

Previous Employment Company Name

Previous Employment Company Phone

Previous Employment address

Previous Employment Company Supervisor

Previous Employment Company Job Title

Previous Employment Company Responsibilities

May we contact any of your previous supervisors for a reference?
Yes   No  

What departments do you wish to obtain externship hours that will fulfill your course objectives? Choose your number one choice here and you can fill in alternates on the next line. *
Cardiac Rehab   Pulmonary Rehab   Physical Therapy   Occupational Therapy   Wellness Services: employee screening, wellness coaching, ancillary programming options   Personal Training – Group fitness   Youth programming, fitness and wellness services   Aquatics programming   Outcome management   Clinical Exercise Physiologist   Other  

Specifiy other and/or list any additional departments you wish to obtain internship hours that will help fulfill your course requirements. *

Please provide a brief bio: (who are you, what are your goals for the internship & for your future, why are you a good candidate for this program). Particularly any ties to our organization, valley or state: *

Certifications: (i.e. CPR/AED, Personal trainer, etc)

By typing my name here I certify that my answers are true and complete to the best of my knowledge. If this application leads to internship, I understand that false or misleading information in my application or interview may result in my release. *