Student Observation Request Form

Student/ Intern Observation Request

Application for undergraduate/ graduate students
Student Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
Where are you looking to complete your hours?
Number of hours needed for program requirement: (if in SC, please specify which city)
ex: I need 10 observation hours, I need one semester of clinical hours, I need to complete my CFY
Education Details

College/ University NameDegree Pursuing (undergraduate, graduate, post-bacc, etc..)
Prospective Graduation Date:

MonthDayYear
Date
Department
Name of School Supervisor(s) & contact info

First/ Last NamePhone # or email

Student Availability Request: (choose multiple choices)

Anything you would like to share about your expectations of our program?
Looking to the future - How interested would you be in pursuing employment at Southland upon completion?
What will influence your decision to work in the Savannah, Ga and Sc areas?
(ex: moving out of the area, pursuing therapy in a non-pediatric setting..)
Should be Empty:

Student/ Intern Observation Request