Health Science Practicum

Applicant Information

First Name

Last Name

Address

City

State

Zip

School Email Address

Cell Phone Number

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Student ID Number Major/Concentration Course Number Semester and Year of Practicum Please list any previous clinical experience you have.

Please provide at least three locations/areas (CITY) you would be able to attend your practicum.

Please provide your top three areas of interest in your field (example: diabetes management, cardiac rehabilitation, senior nutrition, physical therapy, etc.)

Are there any items of concern that you feel are necessary to discuss? If you have health related or background check concerns, please indicate “Meeting Request” here.

Schedule of Availability

I have been advised that I am required to complete minimum of 90 hours of practicum experience at the selected site prior to the last week of the semester. I understand that I must complete at least 50% of hours by the end of the 8th week of the semester. I will notify the Clinical Coordinator and my Course Instructor if I have not met these requirements. I have received and reviewed the Practicum/Field Experience Manual.