Student Athletic Trainer Application

Email Secondary Email

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Personal Information:

Name *

Phone: *

Email address *

Parents Name(s): *

Parent(s) Occupation: *

Permanent Address: *

City: *

State: *

Zip Code: *

Education

High School: *

City and State: *

Date of Graduation (Month and Year): *

Class Rank: *

High School GPA: *

Honors, Athletic and Extra-Curricular Activities, Etc:

Athletic Training Experience

High School: *

List Dates and Sports

Clinics Attended:

Why do you wish to become an Athletic Trainer: *

Are you interested in entering the athletic field after graduation? *

If no, what field of work to you expect to enter?

Have you had any First Aid training? *

Have you had any CPR training? *

References

Personal References: *

Please list at least three personal references below. At least two of them should be coaches or teachers that you have worked with in the athletic training or athletic field. Please have them send a personal letter of recommendation to me as soon as possible.

Additional Information

Shirt Size *

Please enclose a recent photograph of yourself if available. Send the completed form and personal references to the following address as soon as possible.

Amanda Maiden

Head Athletic Trainer

Butler Community College

901 S Haverhill Rd

El Dorado, KS 67042

316-322-3220

* required field