Student Experience Request Form

Medical Associates Clinic

To be considered for a student experience at Medical Associates, please complete the following information at least 45 days prior to your desired date of experience. Human Resources will contact you if we can accommodate your request.

If you have any questions, please contact Human Resources at (563) 584-4225. Thank you.

Personal Information

First Name:*

Last Name:*

Preferred First Name (if applicable):

Street Address:*

City:*

State:*

Zip Code:*

Home Phone:

Preferred

Cell Phone:

Preferred

Other Phone:

Preferred

Email:*

School Information

School Name:*

School Street Address:*

School City:*

School State:*

School Zip Code:*

Program Director/Contact Person Name:

Program Director/Contact Person Phone Number:

Program Director/Contact Person Email:

Program Director/Contact Person Fax Number:

Are you currently enrolled in a school program?:*

Yes

Please list the program(s) you are currently enrolled in:*

What year of study are you currently enrolled in:*

Expected year of graduation:*

When do you expect to enroll in a school program?:*

Please describe your school enrollment plans:

Have you rotated at Medical Associates before?:*

Yes

Please list dates, departments, physician name, etc.:*

If your name has changed, please list details here:

Student Experience Request

Which student experience are you requesting?:*

Hands-on Required Rotation Experience

Observation Experience

Is the Observation Experience required?:*

Yes (It is class requirement, prerequisite for the Masters program, etc.)

No (It is optional or for informational purposes only)

How many hours are you requesting?:

What is your desired start date?:*

What is your desired end date?:*

Do you have a need for a certain department and/or provider?:*

Yes

What Department(s) and/or Provider(s) are you requesting?:*

What Department(s) and/or Provider(s) are you interested in?:*

List the days of the week/hours you are available:*

Please select available start and end times for each day of week

Day Of Week

Start Time

End Time

Monday

Tuesday

Wednesday

Thursday

Friday

How did you hear about Medical Associates?:*

Briefly describe how you heard about Medical Associates:*

ie: Website, newspaper, etc.

Why are you choosing Medical Associates?:*

In a brief statement what are your career goals for the next 2-5 years?:*

Additional Information:

Please allow at least two weeks for our Human Resources department to review and respond to your request. Students will be expected to adhere to the same policies and procedures as our employees, please review the policies and procedures on the following page.

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