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2020 EFM Student Participation Form
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* Indicates required question
Email
*
Your email
Last Name
*
Your answer
Firs Name
*
Your answer
Address:
*
Your answer
Age
*
Choose
16
17
18
19
Parent Name
*
Your answer
Cell number
*
Your answer
Parent Name
*
Your answer
Cell Number
Your answer
Are you willing to attend an overnight retreat the night of the program?
*
Yes
No
Required
Are you willing to participate in a simulated traffic collision?
*
Yes
No
Maybe
Would you be willing to be the critically injured patient in the collision?
Yes
No
Clear selection
Would you be willing to be the patient that dies in the collision?
*
Yes
No
Would you be willing to read your letter to the audience at the assembly?
*
Yes
No
Maybe
Would you be willing to play the part of the impaired driver?
*
Yes
No
For the EFM program to be effective, it is recommended that you do not discuss this program with other students or faculty. Can you do this?
*
Yes
No
Why would like to participate in this program?
*
Your answer
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