Student Experience Inquiry Form

Thank you for your interest in a student experience at GHC-SCW! We require that students be 18 years or older and have already completed at least a high school degree or the equivalent.

You can expect a response within 2 weeks after submission.

Your role:

Do you have your Manager or Clinic Medical Director's approval to accept a student?

Your Name

First NameLast Name

Your Email

example@example.com

What level of learning experience is being requested for this student?

Other

In which department are you requesting a student experience?

Student's Name

First NameLast Name

Student's Pronouns

Student's Email

example@example.com

Student's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Is the student older than 18 years old with a completed high school degree (or equivalent degree)?

Student's School

Program Student is Enrolled In

Estimated Start Date

Date

Estimated End Date (If Available)

Date

What are the time requirements for the requested rotation? (How many hours per week? Per semester? Length of rotation? Total hours needed?) Enter "not known" if information is unavailable.

Has a provider at GHC-SCW already expressed a willingness to serve as a clinical preceptor, instructor or supervisor? (If you are the provider, indicate "Yes".)

Potential Instructor's Name and Clinic Location for the Rotation (If Known)

Does the student need to participate in an improvement project while they are at GHC-SCW?

Describe the needed improvement project.

At this time, GHC-SCW does not offer learning experiences for students under 18 years old without a high school degree.

Please note: Your information will be shared with our provider group asking for a preceptor for you but there is no guarantee for placement.