ACMC Health Student Rotations/Shadowing
Application Form

I am a:

High School Student

Advanced Practice Student

Other:

Medical Resident

Medical Student

 

Apply for:

Rotations

Shadowing

 

Name:

Phone:

Birth date:

Email:

Present address

Address:

City:

State:

Zip:

Permanent address

Address:

City:

State:

Zip:

schooL

School:

Grad. year:

Current year
in school:

GPA (High
school):

Faculty

Contact:

Email:

Phone:

Fax:

 

Requested clinic location:
(Your request may not be available and may be assigned)

 

Requested starting date:

Requested ending date:

 

Requested preceptor/mentor:
(Your request may not be available and may be assigned)

 

Do you have health insurance?

Are your immunizations up-to-date?