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:



Area of Interest


Availability

Please indicate the days you are available to observe. Observation hours vary dependent on requested hours and availability of preceptors.



Additional Information

Please check any applicable boxes below indicating why the experience is needed/requested.


Prerequisite for application to a degree program--Need experience to be considered for a program and will not be sponsored by a school.


Required experience for a current class or program--Already enrolled in the class or program and need experience for completion or requirements.


Personal experience not related to school requirements.



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.