Student Rotation Request

Please fill out this form in its entirety to be considered for a rotation.  You are required to upload a CV/resume and a brief bio outlining your ties to the Flathead Valley or Montana before submitting.

We cannot guarantee placement as it is up to the individual preceptor and manager of the area requested.
 

1. Today's Date *

2. First Name *

3. Last Name *

4. Phone Number *

5. E-mail address *

6. School Name *

7. Program *

8. Course Number *

9. What academic rank is this program? *
Certificate   Non-Credit   Licensure Training   Associate of Applied Science   Certificate of Applied Science   Associate of Arts   Associate of Science   Bachelor of Arts   Bachelor of Science   Master's Degree   Doctorate   Medical Doctor (MD)   Doctor of Osteopathy (DO)   Physician Resident  

10. Please Copy and Paste Couse Description Here *

11. Rotation Start Date *

12. Rotation End Date *

13. Number of Hours Required *

14. Advisor, School/Residency Contact or Instructor Name *

15. Advisor, School/Residency Contact or Instructor email *

16. What type of rotation are you requesting? *
Family Medicine    Geriatrics    Internal Medicine    Pediatrics    Urgent Care    Women's Health/OB-GYN    Cardiology    Oncology    Emergency Medicine    Genetic Counseling    Psychiatric    Neurology     Speech Language Pathology     Physical Therapy     Occupational Therapy   

17. If your rotation type is not listed above, please specify below.

18. Have you been in contact with someone willing to be your preceptor? *
Yes   No  

19. If so, what is the preceptor's name?

20. If you are requesting a specific provider and have not spoken to them directly, please provide the name

21. Preceptor Qualifications choose all that apply *
MD or DO    NP    PA    Other   

22. If other, please specify.

23. Please upload your CV/resume here *


24. Please upload your bio here *


25. Upload a current, conservative, professional photo *


26. Are you currently employed at Logan Health? *
Yes   No  

27. If so, where do you work?