Shadowing Application

First Name

Last Name

Street Address

City

Zip Code

State

Country

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.

Are you currently In school?

YesNo

Graduation Date

Preferred Sea Mar Preceptor

Preferred Sea Mar Clinic

Click here to see clinic locations

Proposed Shadowing Dates

Proposed Total Shadowing hours

Educational Level

Please upload your CV