College-Required Observation Experience Request

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Email Address

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Name of School

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Program or course of study

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Is this experience required for your academic program?

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Name of program director or Adviser at your school

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Director/adviser's telephone number

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Director/adviser's email address

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Hospital department or clinic requested

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Number of hours requested if applicable

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Date(s) of observational experience requested

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Does your school have an affiliation agreement with Great River Health?

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Have you received a loan/scholarship or tuition reimbursement from Great River Health System?

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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?

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

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