Clinical Rotations Students

Request for Shadowing Opportunity

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 a shadowing opportunity is available and provide you with next steps.

First Name *

Middle Initial *

Last Name *

Date of Birth *

Address *

Telephone Number *

Email Address *

Institution Name (if applicable)

Expected Graduation Date *

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 ? Yes No

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

Are you a robot? *