Empower SCI Montana: Clinical Specialist Application
Application as a Clinical Specialist for the one week residential program In Montana

Instructions:
Please complete and submit this form by April 1

Staff Training: June 8 and 9, 2019
Program Dates: June 9 to 15, 2019

Email address *
Personal Information
Last Name *
Your answer
First Name *
Your answer
Telephone Number *
Please include an area code.
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Date of Birth *
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DD
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What is your T-Shirt Size? *
Occupation *
Your answer
Will you need housing during camp? *
Emergency Contact *
Who can we call in the case of an emergency?
Your answer
Emergency Contact Telephone Number *
Your answer
Have you volunteered as a Clinical Specialist with Empower SCI's summer program in the past? *
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