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.
Email
example@example.com
Birth Date

MonthDayYear
Where are you looking to complete your hours?

Savannah, Ga (clinic setting)South Carolina (natural environment setting)
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?

Extremely interestedSomewhat interestedNot at all interestested
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