VHP Student Experience Request Form
Please complete the following form to be considered for an educational experience with Valley Health Partners Community Health Center
Name
*
First Name
Last Name
Social Security Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Gender
Please Select
Female
Male
I perfer not to answer
School Name:
Please Select
Cedar Crest College
DeSales University
Kutztown University
Lehigh University
Lincoln Technical Institute
McCann School of Business & Technology
Philadelphia College of Osteopathic Medicine
University of South Florida
If other, please list school here:
Graduation Month and Year:
*
Major:
*
Requested area/clinic/department:
*
Anticipated Start Date:
*
-
Month
-
Day
Year
Date
Reason for Request:
*
Please Select
Additional experience
Externship
Internship
Requirement for college major
Requirement for college minor
Observation/Shadowing
Pre-professional Program requirement
Please list the name of an individual we may contact in case of an emergency.
*
First Name
Last Name
Emergency contact relationship:
*
Please Select
Aunt/Uncle
Colleague
Daughter
Friend
Other
Parent
Partner
Sibling
Significant Other
Son
Spouse
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Submit
Should be Empty: