EmailMeForm
NCAHEC Community Primary Care Rotation Application
To: Greensboro AHEC Student Services
1200 N Elm Street, Greensboro, NC 27401
Contacts:
Terry Lynn, Director, Medical Education – 336-832-7933 | terry.lynn@conehealth.com
Tonya Crawford Baldwin, MA, Student Services – Coordinator. 336-832-8566 | tonya.baldwin@conehealth.com
All housing requests must be completed online at www.myahec.net. A Housing Agreement Form and a $50 security deposit are required. View www.piedmontahec.org for details and payment instructions. Deposit forfeited for no-shows or without 72-hour cancellation. Counties served: Alamance, Caswell, Chatham, Guilford, Montgomery, Orange, Randolph, Rockingham
Please complete the following information.
FROM:
*
Please select:
Duke
ECU
UNC-C
UNC-CH
UNC-G
UNC-W
WCU
WFU
WSSU
Request:
*
New Request
Change in Request
Date
*
MM
/
DD
/
YYYY
Person Completing Form:
*
Phone
*
###
-
###
-
####
Email
*
Student Services is requested to notify school/course contact by:
*
(if placement has not been scheduled)
Student Name
*
First
MI
Last
Sex:
*
Female
Male
Student Phone:
*
###
-
###
-
####
Year:
*
Student Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Student Email
*
Last 4 Digits of SS#
*
Course Name
Degree Sought
*
Please select
ANP
CNM
FNP
GNP
MD
PA
PharmD
PHP
WHNP
Other
Course Director
Course Contact
First
Last
Phone
###
-
###
-
####
Pager or Cell
Rotation Dates
Student/Course Information
I verify that this student is in good standing with the University, has completed all pertinent OSHA training, and is covered for liabitility during this community rotation.
Faculty Course Director's Signature
Clear
Placement Information
We request that the AHEC/Student Services office assist with this student placement.
Special Placement Requests
Preceptor
*
We have tentatively scheduled the above student with the following preceptor:
Practice Name
*
Practice Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Practice Phone
###
-
###
-
####
AHEC Housing
AHEC Housing Requested
*
Yes
No
If YES, students must complete the online AHEC Student Housing Application at http://my.ncahec.net/
