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

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
Date of Birth
MM
/
DD
/
YYYY
What is your T-Shirt Size?
Occupation
Your answer
Will you need housing on SBU campus?
Have you volunteered with Empower SCI as a Clinical Specialist in the past?
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