DAWN Clinic: Med Specialties Student Scheduling
This form is for student care provider role ONLY. Sign up for Tuesday night shifts from 5:30-9:30 PM at the DAWN clinic.
First and Last Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Select your School program/year *
Which Workgroup are you in? *
Type of request: *
Required
Are you currently an active member of PCP? *
Monthly Shifts/Add a Shift
Due to the current size of our workgroup, expect usually 1 shift and 1 possible on-call appointment per month.
List your 1st date preference.
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List your 2nd date preference.
MM
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DD
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YYYY
List your 3rd date preference.
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DD
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YYYY
How many times would you like to volunteer this month?
Your answer
Is this your first time volunteering?
Cancellation/Rescheduling
Please note that reschedules require AT LEAST 48 hours notification unless it is an emergency. If the shift you are attempting to reschedule for is LESS THAN 48 hours away, please contact Derek George directly.
Original Shift (to be cancelled)
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DD
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YYYY
Desired Shift (if there are opening)
MM
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DD
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YYYY
Reason for Canceling
Your answer
Additional Comments
Special Notes regarding SHIFT REQUESTS only
Your answer
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