Request for Student Experience Form

Please refer to the application window schedule to determine when you need to apply for your student experience at Evangelical. Please complete the form below. Fields marked with an asterisk (*) are required. Please complete the request form for a student experience and a hospital representative will contact you within 15 days after the application window closes.

First Name:

Last Name:

Are you over the age of 18?:

Yes No

Do you attend an affiliated school?

Yes No

If yes, please select what college or university you attend or will attend.

If no, please indicate what college or university you attend or will attend.

If you attend a college or university that is not listed and affiliated with Evangelical Community Hospital are you willing to obtain general/professional liability insurance for the duration of your student experience?

Yes No

Current GPA:

Address 1:

Address 2:

City:

State:

Zip:

Phone Number:

Email:

Type of experience requested:

Department/Profession of interest:

Have you already arranged a student experience with a host department/provider at Evangelical Community Hospital?

Yes No

If Yes, please indicate who your contact is.

Are you an employee of Evangelical Community Hospital?:

Yes No

Are you the spouse, partner, or child of an Evangelical Community Hospital employee?

Yes No

If Yes, please indicate who your contact is.

Minimum Number of Hours Requested:

Maximum Number of Hours Requested:

Start Date:

End Date:

What are your career goals/what prompted your request?

Do you have the following clearances (Less than one year old)?

PA State Police Criminal Background Check
PA State Child Abuse History Clearance
FBI Fingerprint Clearance

Proof of MMR Vaccinations:

Yes No

Proof of Influenza Vaccination < 1 year (Only applicable between Nov. 1st and May 1st)

Yes No N/A

Negative TB Skin Test (PPD) < 1 year:

Yes No

Application Window	Experience Terms For Experiences Occurring Between
February 1 – March 15	Summer: May – August
May 15 – June 30	Fall: September – December
October 1 – November 15	Spring: January – April