CommUnityCare Observership Application Form

CommUnityCare Observership Application Form

Thank you for your interest in CommUnityCare!

Please read below before submitting if you are applying for an observership/shadowing experience.

The Department of Education and Research at CommUnityCare has deadlines for each applicable term for accepting requests:

Spring Term Deadline: November 30

Summer Term Deadline: March 30

Fall Term Deadline: June 30

If approved, The Department of Education & Research will reach out to you directly with instructions for collecting all supplementary onboarding paperwork required.

Students must be able to provide an attestation letter signed by their clinical coordinator clearing them of satisfactory background check and immunizations.

***If you are not able to obtain an attestation letter from your school, you will need to provide your own satisfactory background check and proof of immunizations. These costs are independent of CommUnityCare and are at the responsibility of the student. A member of our team will reach out to you directly with next steps and instructions for submitting these confidential items.

Incomplete applications and requests submitted beyond the deadline dates will not be considered. Deadlines are critical in meeting the follow-up requirements in the event the student's rotation request is approved.

Please note that the Department of Education and Research will evaluate each application on a case by case basis to determine applicants appropriately.

Be sure to send a copy to yourself and preceptor (if applicable) for your records. A completed form does not guarantee placement.

For questions please contact: Educationandresearch@communitycaretx.org

Today's Date*

Preferred Term*

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First Name*

Last Name*

Ethnicity*

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Email Address*

Phone Number*

Date of Birth*

mm/dd/yyyy

School/University*

Major or Field of Study*

Current undergraduate or anticipated major or field of study. (Example: BS Public Health)

Anticipated Graduation*

Preferred Clinic Placement Site*

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Who would you like to observe?*

Preferred Start Date*

Preferred End Date*

What are your observation hours?

Full name of Community Care preceptor/sponsor.

Total Hours Requested*

For shadowing opportunities, a maximum of 24 hours (3 business days) is allotted

Clinical Coordinator Name from your School*

Clinical Coordinator Email*

Letter of Intent*

In 3-5 sentences, please explain why you are interested in an observership experience with CommUnityCare.

Referral Source

How were you directed to our website?

CommUnityCare Contact

Do you have an internal contact at a CommUnityCare clinic?

Required Documentation*

Please check If approved, you will be able to provide the supplementary documentation required including:

Background Check (within the last 6 months)

Proof of Required Immunizations

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Additional Comments

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