Student Clinical Rotation Application

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12 Characters
1 Uppercase letter
1 Lowercase letter
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1 Special character

First Name

Last Name

Profession

Street Address

City

State

Country

Zip Code

Telephone Number

How did you hear about us?

Do you speak any of the following languages?

Do you speak any other languages?

Please describe why you are specifically interested in Sea Mar Community Health Centers, and serving the underserved population at our clinics.

Name of Graduate School

Graduation Date

Preferred Sea Mar Preceptor

Sea Mar Clinic

Click here to see clinic locations

Proposed Rotation Dates

Would you be interested in employment or Residency Training at Sea Mar after graduation?

YesNo

Please upload your CV

Does your educational institute have an active affiliation agreement with Sea Mar Community Health Centers?

YesNo (due to the high number of requests for student placements, we are only able to consider those in which we currently have an established affiliation agreement)

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Contact Information