Clear Creek Health Science Clinical Program Application
Formerly known as HST II - Clinical Rotations
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Student's First Name *
Student's Middle Name *
Student's Last Name *
Student ID Number *
Please include any leading zeros present in your ID number.
Student Birth Date *
(mm/dd/yyyy)
MM
/
DD
/
YYYY
Student Social Security Number *
For now, only enter the last 4 digits of your Social Security Number.  We will need the full number later when the hospital/pharmacy runs the criminal background check on you.  If you don't have one, please write 'None' in the box
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