Providers
Locations
Services
Patients & Visitors
Careers
Bill Pay
Patient Portal
Providers
Locations
Services
Patients & Visitors
Careers
Bill Pay
Patient Portal
This application must be completed in its entirety and submitted with documents listed
APC Placement Application
Step 1 of 4
25%
Personal Information
Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
How do you prefer we contact you?
*
Email
Phone
Are you an associate of Beacon Health System?
*
Yes
No
Associate #
Date of Hire
Date Format: MM slash DD slash YYYY
Current Position
*
Department
*
Manager Name
*
Entity
Manager Email
Institution and areas of interest
What school do you attend?
*
Advisor Name
*
First
Last
Advisor Email
*
Advisor Phone
Degree Pursued
*
Anticipated Graduation Date
*
Date Format: MM slash DD slash YYYY
Where do you see yourself practicing following graduation?
*
Primary Care
Urgent Care
Surgical Specialty
NICU
Women’s Health
Request Rotation Information
Please list ALL rotation requests, including the specialty, dates, and hours. All requested rotations and dates must be accurate and verified by your school. Any incorrect or unverified information may result in placement delays or inability to secure a placement. PLEASE NOTE: Preceptor/Location requests will not be guaranteed
List
Name of Rotation (Specialty)
Location Request (i.e. South Bend, Kalamazoo):
Preceptor Request:
Number Hours Required:
Dates
Personal Statement
Personal Statement (required): In two paragraphs or less, please describe what you hope to achieve by pursuing this degree?
