Medical Student Rotations & Shadowing

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Medical Student Rotations

Instructions for students seeking rotations or career shadowing.

Thank you for considering Lakeview Clinic for a rotation or career shadowing. Please fill out the request form below in order to begin the application process. Please be as thorough and accurate as possible. Once we receive your information, we will review your submission and be in touch with you soon.

Completion of this form does not guarantee we can accommodate your request. We may request additional information such as a student resume or CV. Please allow one week for a response. If you have not been contacted within that time or have additional questions, please contact our administrative office.

Request Form

Medical Student Rotation & Shadowing Application

First Name

Middle Initial

Last Name

Birthdate

Are you a U.S. citizen?

Yes

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Local Emergency Contact First Name

Local Emergency Contact Last Name

Relationship to applicant

Emergency Contact Phone/Mobile #

School Name

School/program location (city/state)

Current School Program/Year

Expected Date of Graduation

First name of school/program contact

Last Name of school/program contact

School contact email address

School contact phone #

Current Program

If current resident, list residency program

High School

Undergraduate (type N/A if not applicable)

Residents, list Medical School(s) - (type N/A if not applicable)

Medical license/credentials

Desired Rotation

Select all provider types that meet your rotation or shadowing requirements.

Preferred Rotation Start Date

Secondary Preference of Rotation Start Date

Total number of hours needed

Select One

What rotations have you already completed and where?

Indicate specialty or area of interest you plan to pursue

Upon completion of medical school, what kind of practice to you envision having?

Additional comments or pertinent information

Send us your information if applicable.

Upload CV &/or Resume

Please check each box to confirm you have read and understand the following:

All communication regarding possible rotations/questions must be between the school and Lakeview Clinic administration.

All forms/requirements must be submitted at the same time. Applicants with missing documentation may not be considered.

Submission of application and required documentation does not guarantee approval of the rotation. Lakeview Clinic will notify the program representative if the requested rotation has been approved or if they are unable to accommodate a rotation.

It is a requirement to wear the ID student badge provided by Lakeview Clinic at all times during a rotation. The ID badge must be returned to the site contact on the last day of the rotation.

By submitting your personally identifiable information "PII", such as your name, email address or contact number to us, you consent to our privacy policy and the use of this information for the purpose for which it is submitted. Lakeview Clinic will treat your information as confidential and follow acceptable safeguards to protect your submitted PII. However, any transmission of PII over the internet is made at your own risk.

Applicants Signature

As a student who will be involved in a career shadowing or mentoring activity at Lakeview Clinic, you may learn of or have access to confidential information. This information may include, but not be limited to: patients' records, conversations, health status, financial information & employee's conversations, financial information, health status. As a condition of my agreement to career shadow an employee, I will not access confidential information and understand that I am responsible for any misuse or wrongful disclosure of confidential information. I understand that my failure to comply with this agreement may result in legal liability and other consequences.

Parent (signature required for high school students)

Medical Student Rotations & Shadowing

Instructions for students seeking rotations or career shadowing.

Request Form

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