Student Request for Clinical Preceptor
Complete this form to begin the process of requesting a clinical site and preceptor. ver 04/2018
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
School Name *
Your answer
Which program are you in? *
Which clinical rotation do you need? *
You need to submit additional forms for each rotation or use the note to staff section to list the additional clinicals with approx stat date and specialty.
How many hours do you need for this rotation? *
Your answer
Which state(s) are you willing to travel to for this rotation? *
Required
Do you have a Compact License? *
When is your paperwork due? *
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When does your semester start? *
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YYYY
When does your semester end? *
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DD
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YYYY
How many clinical rotations do you need in total?
Use this area to send a note to the Clinical Match Me staff
Your answer
Submit
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