Preceptorship Form

First Name *

Last Name *

Gender *

Email Address *

Phone Number *

City of Residence *

State of Residence *

University *

City of University *

State of University *

Expected Date of Graduation *

Select your field of study

Number of clinical hours needed *3 max characters.

Clinical Rotation Start Date *

What is the date when you are allowed by your university to begin your clinical rotation?

Rotation Preference

In Person

Telehealth

Hybrid

No Preference

Please keep in mind that your university may not allow telehealth and/or hybrid. Be sure to confirm with your school

Are you willing to travel?

Years of preceptor experience required

1 Year

2 Years

More than 2 years

No Requirement

Some schools require that your preceptor must have a certain amount of professional experience

Additional Comments Please let us know if you have any additional comments or you'd like to clarify any of your responses