Contact Information

First Name *

MIddle Name

Last Name *

Preferred Email Address *

Phone Number *

Current Address

Address *

Apartment/Suite #

City *

State

Zip *

Permanent Address

Same as current address

Address

Apartment/Suite #

City

State

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

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 must be submitted at least 8 weeks prior to each term, but no earlier than 6 months ahead of the term start date.

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 *

As you get closer to your next big goal, the APP Recruiters at WellSpan Health want to be able to share future job opportunities that could shape your career. Click here to connect with a member of our team.

Commitment to community health and wellness

WellSpan Health and its employees have a shared mission of "working as one to improve health through exceptional care for all, lifelong wellness and healthy communities."

By submitting an application, you agree to uphold our commitment to protect our patients and promote a healthy environment.

Additionally, your commitment would include:

Being drug-free
Being tobacco- and nicotine-free
Being fragrance-free (no colognes, perfumes or scented body products)
Obtaining an annual flu vaccination (for all rotations with any dates between Oct. 1 and March 31)

Questions with an (*) require information to be entered in order to submit your application.