Observational Experience Application
Name
Address
City
State
Zip
E-mail address
Phone
Country of Citizenship
Social Security #
Name of School
Year in School
Course Name (if applicable)
Personal Statement (what do you expect to gain from this experience?)__________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
INFORMATION ABOUT REQUESTED EXPERIENCE
□ Yes
Have you made contact with a person/department:
□ No
Date(s) requesting________________________________________________________________________________________
Physician/medical staff/department_____________________________________________________________________
Have you been a student or volunteer at UPHS in the past?
□ Yes
________________________________________________________________
Learner Signature/parent if under 18
□ No
____________________________
Date
For Office Use Only
Date(s) of Experience
Department
Physician/Staff
Approved by_________________________________________________ Date______________________
Comments_____________________________________________________________________________
Return to: UP Health System – Portage
ATTN: Human Resources
500 Campus Dr
Hancock, MI 49930