Request for Clinical Rotation

Please complete all required fields in the submission form below. Once completed, a member of our medical education program will contact you to inform you whether the requested clinical rotation is available. If available, you and/or your program coordinator will need to provide an Institutional Affiliation Agreement that will be reviewed by our legal department. This process can take 4-6 weeks for approval and must be completed prior to scheduling your rotation.

Student Requirements

Currently enrolled and in good-standing with learning institution
Ability to travel to various health centers depending on availability
Fluent in spoken and written English

Request for Clinical Rotation

First Name *

Middle Initial *

Last Name *

Date of Birth *

Address *

Telephone Number *

Email Address *

Institution Name *

Program Type (MD, NP, PA, CNM, etc) *

Year In Program *

Expected Graduation Date *

Program Coordinator Name *

Program Coordinator Address *

Program Coordinator Telephone *

Program Coordinator Email Address *

Requested Start Date *

Requested End Date *

Requested Number of Hours per Week *

Requested Location *

Currently or previously employed by a Planned Parenthood affiliate * Yes No

If yes, please list affiliate and dates of employment

Currently or previously a volunteer at a Planned Parenthood affiliate * Yes No

If yes, please list affiliate and dates of volunteer status

Interested in Working for Planned Parenthood in the future (not required for clinical placement) * Yes No

Personal Statement (optional): Please tell us why you are interested in a clinical rotation at Planned Parenthood Pacific Southwest and/or what you hope to gain from this clinical experience (max 500 words) *

Are you a robot? *