Clinical Rotation Application

Personal Details

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

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Zip Code

Are You Bilingual In English And Spanish? *

• Yes
• No

School Details

Name of School *

Program *

Current Year in School *

Clinical Rotation Options

Preferred Rotation Site

• CWFM Yakima
• CHCW Ellensburg
• Yakima Pediatrics
• Naches Medical Clinic
• Highland Clinic
• CHCW - Corporate
• Senior Residential Care
• Ellensburg Dental Care

Why Do You Want To Complete a Clinical Rotation With Us? *

List the Learning Objectives for your Clinical Rotation: *

Number Of Clinical Hours For This Rotation:

Number Of Hours Per Week You Expect For This Rotation:

Preferred Start and End Dates

First Choice Begin Date

First Choice End Date

Second Choice Begin Date

Second Choice End Date

Once you have submitted this form you should receive an email confirmation that it has been submitted successfully.

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