Clinical Internship Student Registration

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Student Affiliation Registration Form

We look forward to providing an exceptional clinical education experience in our hospital. In the following sections you will review and complete all documents in order to comply with company policies for clinical placements. 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:

Graduation Year:

Address:

City:

State:

Zip:

Phone:

Email:

Discipline:

School Name:

School State:

Clinical Instructor Name:

Clinical Rotation Start Date The dates for the students clinical/fieldwork/internship placement

Clinical Rotation End Date The dates for the students clinical/fieldwork/internship placement

Additional Comments:

CLINICAL HOSPITAL INFORMATION

Clinical Rotation Hospital Name:

Clinical Rotation Hospital City:

Clinical Rotation Hospital State:

Clinical Internship Student Registration

Student Affiliation Registration Form

STUDENT INFORMATION

CLINICAL HOSPITAL INFORMATION

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