Δ Name(Required) First Last Are you a current employee at Glencoe Regional Health?(Required) Yes No Email address(Required) Please provide a valid email address as this will be the main way we communicate with you.Cell phone(Required)Name of school attending(Required)Program of study(Required)Desired rotation area(Required)Number of hours needed(Required)Rotation start date(Required) MM slash DD slash YYYY Rotation end date(Required) MM slash DD slash YYYY Please read and accept:(Required) I understand that if my request is approved, a current affiliation between my school and GRH must be in place. Please read and accept:(Required) I understand that if my request is approved, I or my school will provide malpractice insurance coverage for the dates of my rotation. Please read and accept:(Required) I understand that if my request is approved, I will be required to provide additional onboarding documentation as requested. CAPTCHA
