EKU Students and Faculty
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Academic Institution
Department
Marshall Office Location Interested In:
Please Select
Richmond
Georgetown
Nicholasville
Lexington
How did you hear about Marshall Pediatric Therapy?
Please Select
Through the University
Word of Mouth
Referred by a Marshall employee
Through Social Media
Other
Requested observation date and start/end times
-
Month
-
Day
Year
Date
Please list a minimum of two (2) alternative observation dates below:
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Start and End Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Participation of Students
Please Select
Hands-on
Observation only
Anticipated # of Students
Please provide details below for the assignment associated with this observation time:
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