Student Application

Name(Required)

First (required) Middle Last (required)

Current Address

Current Address(Required)

Street Address (required) Address Line 2 City (required) State / Province / Region (required) ZIP / Postal Code (required) Country (required)

Contact Information

Home Phone(Required)

Cell Phone(Required)

School Email(Required)

Alternative Email(Required)

Permanent Address/State of Residence

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Program Info

University / Residency Name(Required)

Program Name(Required)

If other, please specify

Placement Coordinator

Name(Required)

First (required) Last (required)

Phone(Required)

Email(Required)

Academics

Academic Standing(Required)

Graduation Year(Required)

Academic Year(Required)

Type of Degree(Required)

Community Health Center Placement Sites Requested

1(Required)

2(Required)

3(Required)

Rotation Info

Rotation Dates(Required)

Length of Rotation (hours needed for this rotation request)(Required)

Rotation Specialty(Required)

Other Info

Are you a National Health Service Corps (NHSC) Scholar?(Required)

Are you now, or have you been a Resident of Arizona?(Required)

Do you speak any other languages (if so, please list languages and fluency)(Required)

In your own words, describe your motivation for requesting this placement and in working with an underserved community (100 words or less)(Required)

Verification

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