Advanced Practice Provider Student Clinical Placement Interest Form

Thank you for your interest in Premier Health. We are excited to help you on your journey to become an Advanced Practice Provider. We look forward to getting to know you better.

Please complete the following form: all fields are required.

If you need placement for more than one clinical rotation in a semester, please submit the form for each rotation.

Premier employees are given priority placement. Student placements are not guaranteed.

Full Name *

Email Address *

School Name *

Program Type *

Date Preceptor Information is required by school *

Are you currently a Premier Health employee? *

Premier employees are given priority placement.

Have you found a preceptor who has agreed to the requirements of your clinical experience?

Name and credentials of preceptor

Type of clinical experience needed *

i.e. Women’s Health, Pediatrics, Mental health, Acute care, etc.

Practitioner Types

MD/DO
PA
NP
Other... This choice will expand a text box

Choose all types of disciplines that would be acceptable.

Exact Dates of Clinical experience

Begin date *

End date *

Number of hours needed *