School Rep Application – Preceptorship/Un-Paid Internship Students

Fill out the form below on behalf of your student for consideration for student placement at an Aspirus facility. Please fill out one form per individual student.

You will be asked on the form to attest that your school or organization has an academic affiliation on file with Aspirus and has conducted a background check on the student. It is advised that you verify these things prior to starting this application, as Aspirus will not consider an application for a student of these criteria are not met. Please note that submission of this form is not a guarantee of the student's placement at Aspirus.

SCHOOL INFORMATION

* Denotes required field


STUDENT INFORMATION


PLACEMENT PREFERENCES





















































INFORMATION VERIFICATION



ADDITIONAL COMMENTS


Step 1 of 2. Next: Confirm & Submit