Please complete the following information and click the submit button at the bottom of this form.  You will be contacted by a member of the Athletic Training staff with additional information about the program. 

NAME: 

ADDRESS:

CITY: STATE: ZIP:

PHONE # (WITH AREA CODE):     

DATE OF BIRTH:

E-MAIL ADDRESS:

PARENT'S NAME:

PARENT'S OCCUPATION:

EDUCATION:

HIGH SCHOOL:  

DATE OF HIGH SCHOOL GRADUATION:  

HIGH SCHOOL ADDRESS:

CITY: STATE: ZIP:

HIGH SCHOOL PHONE# : ESTIMATED GPA:

LIST ANY HIGH SCHOOL HONORS:
 

ATHLETIC TRAINING EXPERIENCE:

Number of years as an athletic training student: 

Please list any athletic training workshops, clinics, etc. attended during the last two years:

What sports have you worked with, or played?

Will Athletic Training be your primary field of professional endeavor?  yes  no

 BRIEFLY EXPLAIN WHY YOU ARE CONSIDERING AN INTERNSHIP AS AN ATHLETIC TRAINING STUDENT AT NEOSHO COUNTY COMMUNITY COLLEGE.  THANK YOU FOR YOUR INTEREST IN NCCC SPORTS MEDICINE.

*The form is only a document noting your interest in the program and in no way constitutes an application for admission to NCCC or an offer of a scholarship at this time.*