Rosalind Franklin University of Medicine and Science

Department of Healthcare Simulation

www.

STANDARDIZED PATIENT APPLICATION

Revised 1-4-18

YOUR CONTACT INFORMATION:
Name:
FULL mailing address (street number, street name, apt. #, city, state and zip code):
Phone numbers - Please let us know which # is BEST for us to contact you :
Cell #:
Home/Landline #:
Work #:
Email Address:
How did you learn about our program? NOTE: If you learned about us from a particular person, please type in his/her full name.
EDUCATIONAL BACKGROUND:
Level of education:
Do you have a background in either education or medicine?
If YES, please explain what that background is:
STANDARDIZED PATIENT BACKGROUND:
Do you have experiencing working as a Standardized Patient?
If YES, please explain:
Name of university(s) SP programs:
Name and email address of the SP Educator(s) you worked with directly:
OTHER EMPLOYMENT:NOTE: do not apply for this position if you work full-time.
Do you have other current part-time employment?
If YES, fill out the following information:
Name of employer(s):
Employer’s Phone Number(s) and/or email addresses:
What type of work do you do for employer(s)?
When did you start working there?
Please list definite days of the week and times that you will be unavailable to work for us:
REFERENCES: Please list two references from current or past employers. Include their full names, phone numbers and/or email addresses:
At which campus are you interested in working? Check all that apply:
___ RFUMS North Chicago campus – 3333 Green Bay Road, North Chicago, IL
___ RUFMS Huntley campus – 10370 Haligus Road, Huntley, IL (on the Centegra Medical campus)
___ I’m interested in working at BOTH campuses

Application continues →

STANDARDIZED PATIENT APPLICATION - WRITING SAMPLE
1] Describe an encounter you’ve had with a healthcare professional which was significant, leaving you with a positive impression of the healthcare field.
2] Describe a teacher who made a significant/positive impact in your education.
3] Why are you interested in becoming a standardized patient?

Please email your completed application, employment resumeand/or theater resume and a recent photo of yourself to:

For work at RFUMS North Chicago campus:

For work at RFUMS Huntley campus:

Or you can mail your application materials to:

Rosalind Franklin University of Medicine and Science

3333 Green Bay Road

North Chicago, Illinois 60064

ATTN: Barbara Eulenberg, Dir. of SP Education

Upon receipt of your application materials, we will review your application to determine if you meet the requirements of our program. If you do, then we’ll contact you to set up an interview/audition.

Thank you for your interest in our program!

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