Student Observation Request

Observation Request

Please fill out the form below to express your interest in observing one of our Speech, Physical, or Occupational Therapists. If under the age of 18, please complete with your Parent/Guardian.Settings
Fusion Therapy Center - Student Observation Request

This form is for junior high, high school and/or undergraduate students seeking observational experience only (no hands-on participation). Observation experiences are limited in duration and are for educational exposure only. Observers do not provide treatment or interact independently with clients. Please complete the form below to express your interests in observing Speech, Occupational, and/or Physical Therapists. If you are under the age of 18, you will be required to provide a parent/guardian contact and signature.
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Primary Email Address (all scheduling communication will take place via email)*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
School Information
School Name
Junior High StudentHigh School StudentUndergraduate College StudentOther
Observation Request Details

Enter additional dates ONLY if needed (up to 3 days total in one request).
Physical TherapyOccupational TherapySpeech Therapy
Primarily PediatricsPrimarily AdultsA mix of Pediatrics and Adults if available
Fill in the box below with total days of observation requested:
Number of Observation Days Requested*
*Max of 1 day for Junior High or High School Students *Max of 2 days for Undergraduate Students
TOTAL Hours of Observation Requested:*
Please provide at least 2 dates of availability in order of preference below. Include the hours requested for each date selected.

*If we are unable to accommodate the dates requested, communication regarding possible alternatives will be made via email upon receipt of this form
Requested date of observation:*

MonthDayYear
First Preferred Date of Observation
Hours Requested (there is a maximum of 6 hours per observation date)*
Requested date of observation:*

MonthDayYear
Second Preferred Date of Observation
Hours Requested (there is a maximum of 6 hours per observation date)*
Requested date of observation:

MonthDayYear
Optional 3rd date
Hours Requested (there is a maximum of 6 hours per observation date)
What is your preferred schedule availability for observations? *
*Our schedule is as follows: Monday-Thursday 8am - 6pm and Fridays 8am - 12pm
Learn more about a potential career pathFulfill a set number of observation hours required by my schoolWork consistently with 1-2 therapists to gain a deeper understanding and potentially earn a letter of recommendation for program applicationsOther
Why are you interested in observing therapy at our clinic?*
How did you hear about our clinic?*
What are your career goals within the healthcare or therapy field?*
Please read the following statements carefully. By checking the boxes and providing your signature below, you affirm that the information is true and agree to uphold these terms during your scheduled observations.*
YesNo
Adult Observer Signature (18 or older) agreeing to our terms and conditions above*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Name (if the observer is under 18)*

First NameLast Name
Parent/Guardian Email (if the observer is under 18)*
example@example.com
Parent/Guardian Phone Number (if the observer is under 18)*
Please enter a valid phone number.Format: (000) 000-0000.
Yes, I give my consent
Parent/Guardian Signature (if the observer is under 18)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Observation Request

Fusion Therapy Center - Student Observation Request

School Information

Observation Request Details