Self-Arranged Externship Site Intake Form
If you're a student who has either already secured a potential placement with a facility or is looking to arrange your own externship, please fill out the provided form. This will enable our externship coordinators to set up the necessary affiliation agreements, ensuring your participation in the externship program.
Your Full Name & Program Enrolled In
The full name of the facility
Contact Person
Title
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Facility's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you have any documents you'd like to add, please upload
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Is there any other information or specific requirements you would like to share regarding the clinic/ site you are seeking placement?
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