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Undergraduate Preceptorship Application
* Required
Applicant Information
Section Instructions: This application is for UC Davis Medical Center employees independently looking for a preceptorship to complete academic coursework. Please note that if an applicant has not yet secured a preceptorship, placement is not guaranteed. After submitting this application, you will then be contacted by the School Liaison regarding preceptorship availability and/or preceptorship clearance requirements. All your questions can be directed to the School Liaison at hs-schoolliaison@ucdavis.edu Thank you.
*1. Applicant Name:
Max Characters: 1000
*2. Date of Birth:
Max Characters: 1000
*3. Last 4 Numbers of Social Security:
*4. Applicant Phone Number:
Max Characters: 1000
*5. Applicant Email Address:
Max Characters: 1000
*6. Applicant Current Mailing Address:
Max Characters: 1000
*7. Today's Date:
Emergency Contact
*8. Name of a relative not residing with you:
Max Characters: 1000
*9. Relationship:
Max Characters: 1000
*10. Emergency Contact Phone Number:
Max Characters: 1000
11. Emergency Contact Email Address:
Max Characters: 1000
12. Emergency Contact Mailing Address:
Max Characters: 1000
School Information
*13. Name of School:
Max Characters: 1000
*14. School Address:
Max Characters: 1000
*15. Student Program of Study:
Max Characters: 1000
*16. School Faculty Name:
Max Characters: 1000
*17. School Faculty Email Address:
Max Characters: 1000
18. School Faculty Phone Number:
Max Characters: 1000
*19. School Placement Coordinator Name:
Max Characters: 1000
*20. School Placement Coordinator Email Address:
Max Characters: 1000
21. School Placement Coordinator Phone Number:
Max Characters: 1000
*22. Semester/Quarter:
Max Characters: 1000
*23. Clinical/Preceptorship Start Date:
*24. Clinical/Preceptorship End Date:
*25. I am looking for clinical experience in (for multiple selections - press "Ctrl" key and then click on choices):
Employment
*26. Are you a current UC Davis Medical Center Employee?
27. UC Davis Medical Center department/clinic:
Max Characters: 1000
28. UC Davis Medical Center department/clinical supervisor name:
Max Characters: 1000
Sponsor/Preceptor Information
*29. Have you secured a UC Davis Medical Center preceptor?
30. UC Davis Medical Center Preceptor Email/Invitation Received?
31. UC Davis Medical Center Preceptor Name:
Max Characters: 1000
32. UC Davis Medical Center Preceptor Phone Number:
33. UC Davis Medical Center Preceptor Email Address
Max Characters: 1000
34. UC Davis Medical Center Preceptor Department:
Max Characters: 1000
35. UC Davis Medical Center Preceptor Department Manager Name:
Max Characters: 1000
OPTIONAL Please enter your email address if you wish to receive a copy of the form data that you are submitting: