Application for Clinical Observation

Application for Clinical Observation

Are you at least 16 years of age?*

Yes

Application Denied

Unfortunately, you do not meet the age requirement to observe. To protect Hendrick patients, employees and students, observers must be at least 16 years of age.

First Name*

Middle Initial

Last Name*

Date of Birth*

Email Address*

Phone Number*

Select the city where you would like to complete observation.*

Select or enter value

Are you an employee of Hendrick Health System?*

Yes

Hendrick Health Campus*

Select

List both the name of the school AND program where you attend/are enrolled.*

Is this observation required for school credit?*

Yes

If this is required for school credit, please list your instructor's name.

List profession you wish to observe.*

List name of person you wish to observe (if applicable).

Have you communicated with the person you wish to observe?

Yes

List number of observation/clinical hours requested.*

Requested Start Date*

Requested Stop Date*

List days of week and times of day you are available.*

Please list additional comments/questions.

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