Eco-Health Bundle Application
CELACare Eco-Health 2-Couse Bundle Application
CELA - The Center for Expressive Living & Creative Arts
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Email *
Name *
Address *
Phone number *
Alternate phone number
I am currently enrolled in college/university *
If yes, name of school and the program in which you are currently enrolled
Do you have a college degree? *
Name and address of high school you attended
Answer this question only if you have never attended college and/or do not have a college degreee
List any certificates and/or certifications you may have *
Current employer *
Include employer name, address, your position, dates of employment, name of your immediate supervisor, and supervisor's contact information
Employer #2 *
Include employer name, address, your position, dates of employment, name of your immediate supervisor, and supervisor's contact information
Employer #3 *
Include employer name, address, your position, dates of employment, name of your immediate supervisor, and supervisor's contact information
Employer #4 *
Include employer name, address, your position, dates of employment, name of your immediate supervisor, and supervisor's contact information
Personal Statement *
Minimum 400 words, maximum 500 words. Can copy and paste essay onto this form.
Additional information
Any information not specifically addressed in other sections of the application that you feel is important can be included here
Recommendations *
List the names of the individuals who will be completing and submitting the recommendation forms/letters in support of your application and their relationship to you
Authorization and Confirmation *
Required
Completing this form *
Write your name and the time and the date that you finished filling out this form in the spaces below. Providing your name as well as the date and the time you completed this form acknowledges that you: (1) have read and understood each individual question and the sections of this form, and the information requested and/or provided; (2) have been given ample opportunity to ask any and all questions you may have; and (3) have provided information that is accurate and correct to the best of your knowledge.
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Please sign/type your full name in the space below to complete this form. Thank you! ---CELA *
A copy of your responses will be emailed to the address you provided.
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