Clinical Internship Student Registration

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Student Affiliation Registration Form

Congratulations on your clinical internship placement with Kindred Healthcare! We look forward to hosting you and providing an exceptional clinical education experience. In the folowing secitons you will review and complete all compliance documents in order to comply with company policies for clinical placements. All sections must be completed in full before you can submit your registration. If you have questions, please contact Meeya Hill at meeya.hill@kindred.com.

STUDENT INFORMATION

Student First Name:

Student Middle Name:

Student Last Name:

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

Address:

City:

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

Zip:

Phone:

Email:

Discipline:

-- Select Specialty -- PT PTA OT OTA SLP DIETETIC PHARMACY OTHER NURSING

Other Discipline:

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

School Internship Coordinator Name:

School Phone Number:

Clinical Internship Start Date 

Clinical Internship End Date 

Additional Comments:

CLINICAL INTERNSHIP 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 Facility Program Director:

Clinical Internship Clinical Instructor(CI)