Waitlist | ElectroPro Software

Become a Model

We welcome members of the community to help our students practice and grow their skills. If you’d like to participate, please complete the form below to request to become a student model. Your involvement supports hands-on learning and makes a real difference in their education.

Initial Contact Date

Initial Contact Date *

Basic Information

First Name *

Middle Name

Last Name *

Date of Birth *

Assigned Gender at Birth *

Male

Female

Preferred Pronouns

Contact Information

Email *

Mobile Phone Number *

Home Phone Number

Address

Country *

State *

City *

Zip Code *

Address *

Address 2

Area Requested

Availability

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Referral

Who Referred You? *

Client Comments

Agree to Cancellation Policy

Please click the link to read the Cancellation Policy before selecting Yes or No.

Yes

Agree to Treatment Policy

Please click the link to read the Treatment Policy before selecting Yes or No.

Yes

Agree to Photo Release

Please click the link to read the Photo Release Policy before selecting Yes or No.

Yes

Client Status

Create A Password

Password *

I have read and understand all policies, and I agree to the terms and conditions of participating as a model client for student practitioners.