Psychiatry Internship Applications Psychiatry Internship Application STUDENT ROTATION FORM This form must be completed 30 days prior to the rotation start date requested. Processing times can take longer depending on how quickly your school responds. Name * Name First First Last Last Date * School * Email * Phone * Alternate Number Address * Emergency Contact * Emergency Contact First First Last Last Emergency Contact Phone * Type Of Rotation Desired: * Full-time Part-time (Specify Hours) * Please provide the specialty you need for this rotation * Rotation start date * Rotation end date * How will you track your hours? Who specifically needs to sign off on them? * Have you completed a clinical rotation with Waterfall Community Health Center before? * Have you already worked to identify a preceptor? * If yes, please provide their name and email address (Respond with NA if you answered no). * What program are you currently in at your school that requires this rotation? * Is your school’s coordinator aware you are requesting this rotation? * If yes, please provide their name and contact information (respond with NA if you answered no). * Have you completed any current bloodborne pathogens and HIPPA training? * References (Optional) Please list the names of references we may contact who have worked with you in the past. Individuals with no prior work experience may list school or volunteer-related references. Name Name First First Last Last Position Company Work Relationship (i.e. supervisor, co- worker) Telephone/Email References (Optional) Please list the names of personal references (not previous employers or relatives) who you know that we may contact. Name Name First First Last Last Occupation Relationship Telephone Number of Years Known APPLICANT CERTIFICATION I certify that all the information on this form is complete and accurate, to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for student rotation. I understand that this practicum/student rotation is done with the consent of the patients. Applicant Signature (Type Here) * Date * Submit If you are human, leave this field blank.
