Cheshire Medical Center Application for Student Placement

Cheshire Medical Center

Application for Student Placement

Please fill out this form to the best of your ability. All information entered will be kept confidential.

Your Full Name*

If you have a middle initial, please include it. This will make it easier to avoid issues with duplicate names in our recordkeeping.

Your Email Address*

Note: if you are a current Cheshire or other Dartmouth Health employee, please use a non-employee email address.

Phone Number*

Mailing Address*

Name Of Educational Institution*

Program of Study (FNP, PA, MLT, etc.)*

Anticipated Date of Graduation

Name of Advisor or Clinical Placement Coordinator

Advisor/Coordinator Email Address

Advisor/Coordinator Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Department(s) where you are seeking placement

Total Hours Requested

Multiple Rotations

Mark this box if you are seeking multiple rotations at Cheshire.

Description of Multiple Rotations

Please describe the different rotations requested (e.g., 125 hours in pediatrics; 125 hours in primary care).

Preferred Number of Hours per Week

Requested Start Date

Requested End Date

Preceptor Requirements (e.g., "must be a PA")

Operating Room Request

Please mark this box if you expect to spend time in the OR during your clinical rotation.

File Upload

If you have a resume of prior clinical experience, please add it here.

Drag and drop files here or

Interest in Future Employment

Please mark this box if you are interested in working at Cheshire Medical Center or another Dartmouth Health affiliate in the future.

Vehicle Description

(Optional) If you will need a parking permit for Cheshire Medical Center during your rotation, please add your vehicle's make, model, and color here. This information can be provided later.

License Plate State and Number

(Optional) If you will need a parking permit for Cheshire Medical Center during your rotation, please add your vehicle's license plate state and number here. This information can be provided later.

Please add your Employee ID (Peoplesoft Number) here.

Additional Comments

Use this field to add any additional comments that you would like us to know about your rotation, such as a preferred preceptor, or dates that you are not available.

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