First Name:
Last Name:
E-mail:
Phone:
Street Address:
City
State / Province / Region
Postal / Zip Code
Name of school:
Program:
Current year in school:
Preferred rotation site: Select value CHCW - Corporate CHCW Ellensburg Clinic CWFM Yakima Highland Clinic Ellensburg Dental Care Naches Medical Clinic Senior and Residential Care Program Yakima Pediatrics
Why do you want to complete a clinical rotation with us?
List the learning objectives for your clinical rotation:
Number of clinical hours for this rotation:
Number of hours per week you expect for this rotation:
Preferred date:
First Choice Begin Date:
First Choice End Date:
Second Choice Begin Date:
Second Choice End Date:
Are you bilingual in English and Spanish?
Yes
No
Enter the answer in the box:
9 + 6 =