FIRST NAME MIDDLE NAME LAST NAME

PERMANENT ADDRESS:STREET CITY STATE ZIP CODE

HOME PHONE CELL PHONE WORK PHONE OTHER PHONE

E-MAIL ALTERNATE E-MAIL**Only Gmail or Yahoo e-mail addresses will be accepted

Please indicate the internship site you are applying to:**You may only apply to one site

How did you hear about us?

Have you applied to this internship before?

Were you previously a Clinical Care Extender?

Are you 18 years or older?

Are you interested in the accelerated track?

Glendale Adventist Medical Center (Glendale) St. Francis Medical Center (Lynwood)Citrus Valley Health Partners (West Covina, Covina, Glendora) St. John's Hospitals (Oxnard, Camarillo)Hoag Memorial Hospital Presbyterian (Newport Beach, Irvine) St. Mary Medical Center (Long Beach)Riverside Community Hospital (Riverside)

EMERGENCY CONTACT:NAME RELATIONSHIP

EMERGENCY CONTACTADDRESS: STREET STATE CITY ZIP CODE

HOME PHONE CELL PHONE WORK PHONE

MOST RECENT COLLEGE/UNIVERSITY GRADUATED? MAJOR/DEGREE YEAR IN SCHOOL CUM GPA

OTHER COLLEGE/UNIVERSITY GRADUATED? MAJOR/DEGREE YEAR IN SCHOOL CUM GPA

HIGH SCHOOL GRADUATED? MAJOR/DEGREE YEAR IN SCHOOL CUM GPA

CURRENT CAREER GOAL ALTERNATE CAREER GOAL

PLEASE LIST WHERE YOU WORK (if applicable):

ADDITIONAL LANGUAGES:(Besides English) LANGUAGE 1 FLUENCY LANGUAGE 3 FLUENCY

LANGUAGE 2 FLUENCY LANGUAGE 4 FLUENCY

APPLICANT SIGNATURE DATE

HEALTH CARE TALENT INNOVATIONSAPPLICATION

SECTION 1: PERSONAL INFORMATION

SECTION 2: EMERGENCY CONTACT INFORMATION

SECTION 4: APPLICANT CERTIFICATION

SECTION 3: EDUCATION AND PREVIOUS EXPERIENCE

* Please read the following statement in its entirety, and type your name on the signature line below to verify your agreement to the terms

PLEASE SPECIFY

By my signature below, I certify the information provided above, and any other information in connection with this application form, including the written essay responses, is true, accurate, and completed by myself, the applicant. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for all background reports requested by or on behalf of COPE Health Solutions and/or my desired hospital volunteer site. I understand that I will be required to submit to a background check and that all parts of the background report must comply with the guidelines set forth by my desired volunteer hospital site in order to fulfill the requirements for the Clinical Care Extender Internship.

If applicable, please mark one or more of our other Internship site(s) at which you would consider interning (check all that apply):

Page 1 of 3

1. DESCRIBE PRIOR COMMUNITY SERVICE, EXTRACURRICULAR ACTIVITIES, AND LEADERSHIP EXPERIENCE.(Please type your response in the box below. 1500 character limit)

2. EVALUATE A SIGNIFICANT EXPERIENCE, ACHIEVEMENT, OR RISK THAT YOU HAVE TAKEN AND ITS IMPACT ONYOU. (Please type your response in the box below. 1500 character limit)

3. HOW DOES THE CLINICAL CARE EXTENDER INTERNSHIP FIT INTO YOUR OVERALL CAREER GOAL?(Please type your response in the box below. 1500 character limit)

HEALTH CARE TALENT INNOVATIONSAPPLICATION

SECTION 5: PROMPT RESPONSES

Page 2 of 3

4. HOW WOULD YOU DEFINE THE CORE VALUES OF THIS INTERNSHIP AND IF ACCEPTED, HOW WOULD YOUUPHOLD THESE VALUES?(Please type your response in the box below. 1500 character limit)

5. HOW WOULD YOU UTILIZE YOUR ROLE AS A CLINICAL CARE EXTENDER TO IMPROVE THE PATIENTEXPERIENCE IN A HOSPITAL? (Please type your response in the box below. 1500 character limit)

6. IT IS OFTEN SAID THAT WHAT YOU PUT INTO THIS INTERNSHIP IS WHAT YOU GET OUT. WHAT DO YOU PLAN ON INVESTING IN THIS INTERNSHIP AND HOW WILL YOU FOLLOW THROUGH WITH YOUR INITIAL GOALS? (Please type your response in the box below. 1500 character limit)

APPLICATIONSECTION 5 (continued): PROMPT RESPONSES

HEALTH CARE TALENT INNOVATIONS

Page 3 of 3

Clinical Care Extender Application 121211_GENERALPG1Clinical Care Extender Application 121211_GENERALPG2Clinical Care Extender Application 121211_GENERALPG3

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