Student Application Part I – NP, PA, CNM, CRNA, AuD & Med Students

Fill out the form below to be considered for student placement at an Aspirus facility. Please note that submission of this form is not a guarantee of placement at Aspirus. Requests for this Academic Year will be considered on a case-by-case basis. Requests for the next Academic Year will be considered starting in May/June prior to that Academic Year.

SCHOOL INFORMATION

* Denotes required field

• School or organization: *
• School representative first name: *
• School representative last name: *
• School representative email: *

STUDENT INFORMATION

• Student first name: *
• Student last name: *
• Date of Birth: *
• Personal email: *
• Primary phone:

• Current address: *
• City: *
• State: * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip: *
• Anticipated graduation date: *

Are you a current Aspirus employee? *

Check all that may apply to you:

PLACEMENT PREFERENCES

Select your preferred Aspirus location(s) for student placement (select as many as applicable): *

If placement is not possible at preferred location(s), are you willing to travel to an alternate Aspirus location if available? *

Student Type: * -- select -- APNP (Advance Practice NP) Audiology Certified Nurse Midwife Certified Registered Nurse Anesthetist Doctor of Medicine Doctor of Nursing Practice (DNP) Doctor of Osteopathic Medicine Family Nurse Practitioner Nurse Practitioner (NP) Physicians Assistant PMHNP (Psych & Mental Health NP) Resident

• Specialty: *

  Allergy/Immunology	Anesthesiology
  Audiology	Business Health
  Cardiology	Dermatology
  Emergency Medicine	Endocrinology
  Family Medicine	Gastroenterology
  Hospice & Palliative Medicine	Hospitalist
  Internal Medicine-outpatient	Memory Clinic
  Neonatology	Nephrology
  Neurology	Neurosurgery
  Obstetrics/Gynecology	Oncology-Hematology
  Otolaryngology	Pain Management & Rehab
  Pediatrics	Podiatry
  Psychiatry	Pulmonary & Critical Care
  Radiation Oncology	Radiology
  Rheumatology	Surgery-Cardiothoracic
  Surgery-General	Surgery-Orthopedic
  Surgery-Plastic	Urology
  Walk-in Clinics	Wound Care

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Do you have a preceptor in mind you would like to work with? *

Yes

No

• Preceptor first name:
• Preceptor last name:
• Preceptor location:

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• Total number of hours required to complete: *

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• Rotation start date: *
• Rotation end date: *

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