Standardized Client Interest Form | Fred Wilson School of Pharmacy

Last Name*

First Name*

Date of Birth*

What is your sex?*

Male
Female
Prefer not to answer

What is your e-mail address?*

What is your home phone number?*

What is your cell phone number?*

Do you currently work for High Point University?*

Yes
No

If yes, what is your job title and in what department?*

Voluntary Information (not required) - Ethnicity

Voluntary Information (not required) - Height

Voluntary Information (not required) - Weight

Do you have previous experience as a Standardized Client?*

Yes
No

If you have previous experience as a Standardized Client where did you work?

Would you like us to contact you about participating as a Standardized Client in the HPU School of Pharmacy?*

Which electronic devices do you use? (such as laptop, iPad, desktop, smartphone, DVR, GPS, etc.) - List all that apply.*

Students begin their labs at 9am or 1pm. Each lab can last up to 3 hours. What times can you participate, beginning 30 minutes before the lab period begins? Please mark each time block you can participate*

Name

This field is for validation purposes and should be left unchanged.