College-Required Clinical Request

Request must be submitted a minimum of 4 weeks before requested clinical experience.

If this is a school address, please enter your home address below:

Email Address

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Name of School

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Program or course of study

Please enter your program or course of study.

Is this experience required for your academic program?

Please make a selection.

Name of program director or adviser at your school

Please enter your program director or Adviser.

Director/adviser's telephone number

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Please enter your adviser's phone number.

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Director/adviser's email address

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Hospital department or clinic requested

Please enter your requested hospital or clinic.

Select preferred location

Number of hours requested if applicable

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Date(s) of clinical experience requested

Please enter observational experience requested.

Are you a Great River Health employee?

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If so, what is your job title?

Are you interested in employment at Great River Health after you graduate?

Please make a selection.

Do you have relatives employed, now or previously, at Great River Health?

Please make a selection.

College-Required Clinical Rotation Request