Student Intake Form
Contact Information
Custom ID
Name
*
First Name
Last Name
Email - DO NOT use your school email
*
personal@email.com
Phone Number
*
Please enter a valid phone number.
Are you currently or looking to enroll in a health professions program?
*
Yes
No
Are you currently an employee of Phelps Health?
*
Yes
No
May we contact you regarding employment opportunities?
*
Yes
No
Are you over the age of 18?
*
Yes
No
When will you turn 18?
*
-
Month
-
Day
Year
Date
Parent / Guardian Contact Information
Everyone under the age of 18 must have a parent or guardian digitally-sign a medical release form and provide insurance policy information. We will email the digital forms to your parent or guardian.
Name of Parent / Guardian
*
First Name
Last Name
Email of Parent / Guardian
*
example@example.com
Phone Number of Parent / Guardian
*
Please enter a valid phone number.
Opportunity you are interested in?
*
Job Shadowing
Clinical Rotation
Submit
Should be Empty: