Clinical Rotation Request Form

Questions marked with a * are required
Hello and thank you for considering NMC Health for your clinical rotations. Please fill out the form once for each clinical rotation requested. 
Contact Information
Due to increased clinical requests, we are offering one weekend date and evening rotations to accommodate as many students as possible. Please consider these unique opportunities for your students. Requests will be processed on a first come – first served basis. 

Requests due by:
- March 31 for May - August rotations
- July 1 for August - December rotations
- November 1 for January - May rotations
Date of request
Clinical first day
Clinical last day
Course name/number
Requestor name
Requestor phone
Instructor name
Instructor phone
Requested days of the week
Preferred time of weekday rotation (Saturday rotations are 06:45-18:45)
Please place some additional times that work for you in the box below. There is no guarantee we can accommodate this.   
Total number of students per day
What location are you requesting?
Do you have a specific unit you want to work in?  (two choices)
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