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Internship/ Clinical Experience Opportunity Request
Providence Medical Center: 1200 Providence Rd Wayne, NE 68787
First and Last Name
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Phone Number
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Email Address
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Date of Birth
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Name of School
Year in School
Are you under the age of 19?
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* Complete this Section if Under 19 Years of Age
Parent or Guardian
First and Last Name
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Relationship
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Phone Number
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Department/Occupational Background
Occupation/Department you want internship/ clinical experience in
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Briefly describe your reason for wanting an internship, including learning and career objectives, number of hours you want to intern, observational requirements, etc.
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What date(s) and time(s) you are available for your internship?
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Emergency Contact Name, Relationship, and Phone Number
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Do you have any limitations or special needs which need accommodation? If yes, please explain.
Have you ever volunteered or been employed by Providence Medical Center? If yes, when?
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Vaccination Record
Please indicate all vaccinations you have received:
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Tdap (tetanus/diphtheria/pertussis)
HPV (Human Papilloma Virus) Vaccine
MCV4 (Meningococcal Conjugate Vaccine)
Pneumococcal Vaccine
HepB (Hepatitis B Vaccine Series)
IPV (Inactivated Polio Vaccine)
MMR (Measles, Mumps, Rubella Vaccine Series)
Varicella Vaccine Series (Chicken Pox)
Influenza
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Verification of Accurate Information
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Signature
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