MAHEC SamStudentRequests

NOTE: If you are requesting more than one rotation please complete a request for each rotation. Due to changes implemented as a result of COVID-19, we are currently prioritizing clinical shadowing experiences for students from affiliated schools and programs based on need and availability.

First Name

Last Name

Suffix / Credentials

Phone

School Email

Alternate Email

Academic Institution

Program

Degree

Graduation Date

Hours Needed

Provider Type

Description of Experiences Needed

Desired Outcomes

Semester for Completion of Experience

Are you Dedicated to Practice in a Rural Area?

Desired Start Date

Desired End Date

Academic Supervisor Name

Academic Supervisor Email

Employer

Other Organization

Additional Information