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Empower SCI: Residential Aide Application
Application as a Residential Aide for the two week residential program at Stony Brook University

Instructions:
Please complete and submit this form by April 1.
Notification of Acceptance: June 1.

Staff Training: July 15 and 16, 2017
Program Dates: July 16 to 29, 2017

Personal Information
Last Name
Your answer
First Name
Your answer
E-mail Address
Your answer
Phone Number
Please include an area code
Your answer
Mailing Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
What is Your T-Shirt Size?
Will you need housing on SBU campus?
Are you CPR certified?
e.g. American Heart Association BLS for Healthcare Providers, American Red Cross Basic Life Support for Healthcare Providers, Health and Safety Institute BLS for Healthcare Providers and Professional Rescuers
If not CPR certified, are you willing to become CPR certified prior to Staff Training if accepted into the program?
Have you volunteered with Empower SCI in the past?
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