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 high school and 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 Name
Last Name
Age
*
Date of Birth
*
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Month
-
Day
Year
Date
Primary Email Address (all scheduling communication will take place via email)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
School Information
School Name
Current Level of Education:
*
High School Student
Undergraduate College Student
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)
*
Physical Therapy
Occupational Therapy
Speech Therapy
What population are you interested in observing? (Choose all that apply) *Please note that observation opportunities are limited and not guaranteed*
*
Primarily Pediatrics
Primarily Adults
A mix of Pediatrics and Adults if available
Requested date of observation:
*
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Month
-
Day
Year
Date
Requested date of observation:
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Month
-
Day
Year
Date
Requested date of observation:
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Month
-
Day
Year
Date
Total Observation Time Requested (there is a maximum of 6 hours per observation date)
*
Please Select
1
2
3
4
5
6
Total Observation Time Requested (there is a maximum of 6 hours per observation date)
Please Select
1
2
3
4
5
6
Provide these additional number of hours requested if you requested more than 1 day of observation.
Total Observation Time Requested (there is a maximum of 6 hours per observation date)
Please Select
1
2
3
4
5
6
Provide these additional number of hours requested if you requested more than 1 day of observation.
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)
*
Learn more about a potential career path
Fulfill a set number of observation hours required by my school
Work consistently with 1-2 therapists to gain a deeper understanding and potentially earn a letter of recommendation for program applications
Other
Why are you interested in observing therapy at 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?
*
Yes
No
Adult Observer Signature (18 or older) agreeing to our terms and conditions above
*
Date
*
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Month
-
Day
Year
Date
Parent/Guardian Name (if the observer is under 18)
*
First Name
Last 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.
Parent/Guardian Consent: I give permission for my child to participate in an observation experience at Fusion Therapy Center.
*
Yes, I give my consent
Parent/Guardian Signature (if the observer is under 18)
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: