Thank you for your time in providing information for this form. Please note this form does not serve as an application for the college. This form is to provide East Mississippi Community College Training Staff with the necessary information about you and your sports background. For an application to the college, please visit the EMCC homepage at http://www.eastms.edu. Please remember to confirm your form once you hit the submit key, as hitting the submit key only saves your answers until you confirm your form. If successful, you should receive a confirmation page of the form being submitted. Application deadline for 2016-2017 year is 4/30/16. Only complete applications will be accepted. Thank you again for your interest in EMCC Athletics.



 Athletic Training




PERSONAL INFORMATION
    
Name:
Address: Birth Date(mm/dd/yy):
City: Home Phone:
State: Cell Phone:
Zip Code: Email:
Twitter Handle: Facebook Link:

GUARDIAN INFORMATION   
    
Mother or Legal Guardian: Father or Legal Guardian:
Occupation: Occupation:
Address: Address:
City: City:
State: State:
Zip Code: Zip Code:
Home Phone: Home Phone:
Cell Phone: Cell Phone:
Email: Email:

HIGH SCHOOL INFORMATION  
    
School: Graduation Date:
Address: Grade Point Average (GPA):
City: ACT/SAT Score:
State: Major:
Zip Code:

ATHLETIC TRAINING   
Athletic Training or Sports Medicine Experience (explain):
Ever worked for/with a Certified Athletic Trainer?  Yes  No
 
Are you interested in a career in Athletic Training after college graduation?  Yes  No
List Work, Extracurricular, Volunteer, Community Experience
Why do you want to be an athletic student trainer at EMCC?
What are an athletic trainer's responsibilities?

REFERENCE 1   
Reference #1 Name:
Relation:
Address:
Phone:
Email:
REFERENCE 2   
Reference #2 Name:
Relation:
Address:
Phone:
Email:
REFERENCE 3   
Reference #3 Name:
Relation:
Address:
Phone:
Email: