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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:
-- Select Month --
January
February
March
April
May
June
July
August
September
October
November
December
Graduation Year:
-- Select Year --
2016
2017
2018
2019
2020
2021
2022
2023
2024
Discipline:
-- Select Discipline --
PT
PTA
OT
OTA
SLP
Dietetic
Pharmacy
Nursing
Other
School Name:
School Not On List:
School State:
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Clinical Internship Start Date
Clinical Internship End Date
FACILITY INFORMATION
Clinical Internship Facility Name:
Clinical Internship Facility City:
Clinical Internship Facility State:
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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: