Clemens Internship Order Form

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Complete Internship Budget form

Last Name *

First Name *

Which internship program are you currently enrolled in? *

What is your class period? *

Scrubs - Type *

Female

Male

Scrub Tops Quantity (Min. of 2 required, $28 ea.) *

Scrub Tops Size *

Scrub Pants Quantity (Min. of 2 required, $28 ea.) *

Scrub Pants Size - Cost $28.00 Each *

Scrub Pants length *

CPR - BLS for Healthcare Providers - $10.00 *

Yes

No - Prev. Intern

Clemens Patch - Minimum 2 (Cost = $8.00) *

HOSA Dues = $40.00 *

Yes

Name Tag - Minimum 2 @ $10.00 Each *

Clinical Program T-shirts - $26.00 *

Yes

What is your T-Shirt Size?

Exam Fee - Please choose your program Below

Submit

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