Paramedic Clinical Request

 

This form is for a student to request a clinical internship rotation.  Requests will be honored on a first come first serve basis with appropriate assignments made based on individual student necessity.

PLEASE NOTE:  AT LEAST 1 WEEK NOTICE REQUIRED.

Please identify and describe yourself:

First name
Last name
Instructor

Enter the date of requested clinical:

-- mm/dd/yy

Choose one of the following time options for the clinical rotation:


Choose one of the following clinical location options:


Method to contact you the quickest to let you know if you are approved:

           Phone:   

           E-mail:   

           Pager:    

Comments:


 

 

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Office Of EMS Education
Last Revised:   6 January 2005