Please complete this application form. Once completed, click the submit button at the bottom.


Date

Enter Today's Date



Name and address


Demographic Information


Emergency Contact

In case of emergency, contact:



Rotation Information

NOTE: This application is only for the CURRENT application semester window. Please do not request future semester clinical rotations. The open windows are as follows.


***Spring Semester ~ applications accepted from September 1st - October 15

***Fall Semester ~ applications accepted from May 1 - June 15th

***Summer Semester ~ applications accepted from March 1st - April 15th


If applications are received outside these application semester windows, the application will be declined without notice.



Availability

Please indicate the days you are available for your clinical rotation. Typical rotations are eight to ten hour shifts. Rotation hours vary dependent on requested hours and availability of preceptors.



ACKNOWLEDGMENT

I hereby certify that all information contained in this application is true and correct to the best of my knowledge.

I understand that, in the event of being accepted for any health career educational experience, false and misleading information given through my application or interview(s) may result in termination of the approved experience.