Clinical Internship Faculty Registration

Placement Registration Form

Thank You for placing your student with Kindred Healthcare. In the following sections you will be reviewing required compliance documents and attesting your student meets all requirements to complete their clinical in our facilities. All sections must be completed in full before you can submit your registration. If you have questions, contact Meeya Hill at Meeya.Hill@kindred.com.

STUDENT INFORMATION

Student First Name:
Student Last Name:
Student Email:(valid email required)
Graduation Month:
Graduation Year:
Discipline:
School Name:

School State:
Clinical Internship Start Date
Clinical Internship End Date

FACILITY INFORMATION

Clinical Internship Facility Name:
Clinical Internship Facility City:
Clinical Internship Facility State:
Clinical Internship Setting Type:
Hospital: LTACH - Long-Term Acute Care Hospital
Hospital: Inpatient Patient/Acute
Accute/Inpatient/Outpatient
Facility Program Director:
Facility Phone Number:
Assigned Clinical Instructor
Comments:

Clinical Internship Faculty Registration

Placement Registration Form

STUDENT INFORMATION

FACILITY INFORMATION

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