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Student Intake Form

Your information

Please note this is how AHN will communicate with  you. Please use your most commonly checked email address.

Additional information

Any Other Names Gone By In The Past (respond with NA if this does not apply)

Any Other Names Gone By In The Past (respond with NA if this does not apply)

Any Other Email Addresses You May Have Used to Complete a Rotation with AHN Before (respond with NA if this does not apply)

About clinical rotation

Have you completed a clinical rotation with Allegheny Health Network before?

Not quite. Try again.
  • Yes
  • No

Have you already worked to identify a Preceptor?

Not quite. Try again.
  • Yes
  • No

If yes, please provide their name and email address (respond with NA if answered no)

Is your school’s coordinator aware you are requesting this rotation?

Not quite. Try again.
  • Yes
  • No

If yes, please provide their name and contact info (respond with NA if answered no)

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