Practicum Associated with College-Level Program of Study

Personal Information

Name *

First

Last *

Last

Email *

Phone *

Address *

Address Line 2

City *

State *

Zip *

Date of Birth *

Emergency Contact *

Please include name and phone number

Are you a current or former employee of Dartmouth-Hitchcock Health system? *

Yes

No

If yes, enter location and dates: *

Request Information:

To help us better know you and make decisions about best fit for different sites/projects, please answer the following questions as accurately as possible.

School / Institution: *

Degree /Certificate to be Obtained: *

Expected Completion Date: *

School Address: *

Program Contact Name: *

Program Contact Phone Number: *

Program Contact Email: *

Practicum Information:

Description of Experience Requested (including purpose and learning objectives and tasks that you are seeking to preform): *

Will you receive college credit for this experience? *

Will you receive a stipend from the college for this experience? *

Preferred Dartmouth-Hitchcock location: *

Note: not all practicum experiences are available at all locations

Please describe how this experience will add value to your career path and what you hope to gain: *

Number of hours required: *

Experience Start Date: *

Experience Completion Date: *

Have you established contact with a potential host / department at D-HH? If yes, please provide your contact’s name and enter the details of the conversations:

If there is any additional information that we should be aware in considering your request (ie: specific scheduling constraints)

Please upload any documentation that supports your request. This might include learning objectives, practicum outline, competencies and evaluations required. (Multiple files accepted)

Maximum file size: 52.43MB