Contact Information

First Name *

MIddle Name

Last Name *

Preferred Email Address *

Phone Number *

Current Address

Address *

Apartment/Suite #

City *

State Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Permanent Address

Same as current address

Address

Apartment/Suite #

State Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip

Are you a current WellSpan employee? Yes No

If yes, are you currently in the WellSpan Forgivable Loan Program? Yes No

School Information

School Name *

Clinical Program Family NP Adult Gerontology NP Women's Health NP Primary Care Pediatrics NP Acute Care NP Psychiatric Mental Health NP Neonatal NP Physician Assistant Other

Anticipated date of graduation (MM/YYYY) *

School Coordinator information Name *

Title

Phone *

Email *

Clinical rotation information

If you are requesting placements for multiple terms, please submit an application for each term. These can be submitted at least 8 weeks prior to each term.

Rotation Request *

Please attach your school's course requirements/goals and objectives of this specific rotation request. These requirements must include a list of preceptor qualifications. We require this information to process your application. *

Rotation Location (General Area) Chambersburg Gettysburg Lancaster Lebanon Waynesboro York

Have you been in contact with a provider about precepting? If yes, please list their name and contact information. (Prior agreements are not guaranteed but will be considered by the APP student coordinator team when reviewing application).

Hours required *

Which days of the week will you be available for rotations? Please note that some programs/locations do not offer weekend rotations. Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Start Date (MM/DD/YYYY) *

End Date (MM/DD/YYYY) *

'Please include any additional questions, goals and objectives, requirements, details you would like the coordinator to consider for this specific rotation request.

Upload Resume *

I am interested in discussing potential career opportunities at WellSpan Health. I agree my contact information to be shared with the APP recruitment team.