Student & Observation Request Form

All applicants must be at least 18 years old. Please provide as much information as possible to ensure accurate placement requests. If you have any questions during this process, please reach out to students@wregional.com.

Student First Name*

Student Last Name*

Email Address*

Phone Number*

Current Address (City, State)*

School Name/College

Program Contact Name (Clinical Instructor or Department Administrator)

Program Contact Email

Program Type (i.e., RN, LPN, radiology, MA, etc.)*

Request*

Shadowing is capped at 4 hours. Preceptorships and internships are reserved for students actively enrolled in an Academic program.

Timeframe for Completion*

Number of Hours Needed*

Student Availability (select all that apply)*

AM
PM
Weekends

Requested Department*

Do you currently work at Washington Regional?*

Yes
No

Why are you interested in completing this request with Washington Regional? (Please provide as much information as possible.)*

Enter Code Displayed*

Primary Care Clinics

Urgent Care

Integrative Medicine

Specialty Clinics

Institutes

Facilities

Student & Observation Request Form