Student/Observation Application

Name *

First

Last

Date of Birth *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

School/Facility *

Your school must have an affiliation agreement with Crouse.

Location of clinical experience *

Name of preceptor for experience *

Requested start date *

Anticipated last day at Crouse *

Please contact Education and Professional Development if this date changes. 315-470-7801.

Student type *

Forms Upload

Health Clearance Form *

Click or drag a file to this area to upload.

Medical History Records *

Click or drag a file to this area to upload.

If your Health Clearance form is not signed by your provider please submit your medical history records.

Hold harmless and release form *

Click or drag a file to this area to upload.

Must have witness signature and the printed names must be legible.

Criminal Background Check *

Click or drag a file to this area to upload.

Access to Electronic Medical Record Request Form *

Click or drag a file to this area to upload.

If a clinical student experience you will need access to the Crouse Electronic Medical Record and you must submit this form.

Website

You will receive email informing you if your application has been accepted. Incomplete applications will be denied.

If you do not receive email confirmation (2 days prior to your start date) please contact Education and Professional Development at 315-470-7802.