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
Current Level of Education:

Other
Observation Request Details

Enter additional dates ONLY if needed (up to 3 days total in one request).
Areas of Interest (Choose all that apply)
What population are you interested in observing? (Choose all that apply) *Please note that observation opportunities are limited and not guaranteed*
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
What are you hoping to gain from this observation experience? (Choose all that apply)

Other
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.
Are you under 18 years of age?
Adult Observer Signature (18 or older) agreeing to our terms and conditions above
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.
Parent/Guardian Consent: I give permission for my child to participate in an observation experience at Fusion Therapy Center.
Parent/Guardian Signature (if the observer is under 18)
Date

MonthDayYear
Date
Should be Empty:

Observation Request

Fusion Therapy Center - Student Observation Request

School Information

Observation Request Details