EmailMeForm
Name
*
First
Last
Cell Phone
*
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Campus Mailbox #
Leave this area blank if you are in high school.
Home Address
*
Street Address
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Country / Region
Email
*
Birth Date
*
MM
/
DD
/
YYYY
Major(s)
Minor(s)
Year in School
Please select
Freshman - High School
Sophomore - High School
Junior - High School
Senior - High School
First-Year - College
Sophomore - College
Junior - College
Senior - College
N/A
Student ID #
Wartburg students only.
High School & Grad Year
If under 18, parent/guardian name(s)
Parent/Guardian(s) Cell Phone
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Position/Certification/Experience
Lifeguard/CPR/First Aid
WSI/Swim Instructor
CPR/LG Instructor (LGI)
Upload Group Exercise/Personal Training Certification
*
Previous Employment Experience
Employer
Position
Dates
Employer 1
Employer 2
Employer 3
List three personal or work references.
*
Name
Address
Phone #
Reference 1
Reference 2
Reference 3
List any additional jobs/activities you are involved in (exp. band, chorus, athletic team, student organizations & provide start/end dates):
