Student Rotation Registration Non AMC

First Name*

Last Name*

At which agency will you be completing your internship or clinical rotation?*

For which AHEC region are you requesting housing?*

Start Date of Rotation*

End Date of Rotation*

Expected Arrival Date*

Expected Departure Date*

If you are seeking housing for an ongoing rotation, for which days of the week do you require housing?

In which city or town are you requesting housing?*

Date of Birth*

Gender*

Ethnicity*

Email Address*

Address 1*

Address 2

City*

State

Zip Code*

Phone 1*

Phone 2

Cell Phone

Pager

Fax

Permanent Address 1*

Permanent Address 2

City*

State*

Zip Code*

Is this a rural community?*

Yes
No

Phone 1*

Phone 2

Emergency Contact Name*

Phone Number*

Relationship*

Institution/School*

Department or School sending the student to this rotation*

URL for the agency*

Full address of the agency*

Name, email address, and phone for the contact at the agency.*

First and Last Name of the Preceptor*

Street address for the Preceptor*

City for the Preceptor

State for the Preceptor*

Zip Code for the Preceptor*

Primary Phone Number for the preceptor*

Cannot be the same as the agency

Email address for the Preceptor*

Cannot be the same as the agency

Expected Graduation Year*

From a disadvantaged Background

Yes
No

Planned area of practice after graduation*

Rural
Urban

Spanish Fluency

Yes
No

Dietary Restrictions

Are you allergic to cats or dogs?

Yes
No

Are you allergic to smoke or have asthma?

Yes
No

Other allergies

Other

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701 Camino Del Rio, Suite 320, Durango CO 81301. Call 970-426-4284.
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Student Rotation Registration- Non-AMC