Graduate Level Student Rotation Request

****This is for Graduate Level Student Requests Only****

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.

Rotation Request Form Deadlines:  
Rotation Dates: Request Deadline:  
Jan-May 2022
May-August 2022
August-December 2022
*Please note - dates subject to change and late request exceptions to be approved by Student Affiliation Department  
We cannot guarantee placement as it is up to the individual preceptor and manager of the area requested.

Today's Date *

First Name *

Last Name *

Phone Number *

E-mail address *

School Name *

Program *

Course Number *

Please Copy and Paste Couse Description Here *

Rotation Start Date *

Rotation End Date *

Number of Hours Required *

Advisor, School/Residency Contact or Instructor Name *

Advisor, School/Residency Contact or Instructor email *

What type of rotation are you requesting? *
Family Medicine   Geriatrics   Internal Medicine   Pediatrics   Urgent Care   Women's Health/OB-GYN   Other  

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

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

If so, what is the preceptor's name?

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

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

If other, please specify.

Please upload your CV/resume here *

Please upload your bio here *

Upload a current, conservative, professional photo *

Are you currently employed at Logan Health? *
Yes   No  

If so, where do you work?