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 legal first name: *
• Student legal last name: *
• Student preferred first 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: *

• Specialty: *

  Allergy/Immunology	Anesthesiology
  Audiology	Business Health
  Cardiology	Dermatology
  DNP Leadership Non-Clinical	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: *

+ Add another rotation

ADDITIONAL COMMENTS

Please explain any ties to our service areas and/or your interest in rural medicine (optional):