Placement Request Form for: NP Students and Out-of-State Students

Student Housing Information

Application Submission: Please complete all sections. Submit your request form as soon as your rotation dates are confirmed to ensure timely processing and consideration for housing.
Notification: You will be notified by email or phone once your form is received to discuss your request.
Housing Rates: Housing for out-of-state students, as well as students from private or non-state supported academic institutions, is available at a rate of $75 per week.
Contact Information: If you have any questions, please call (803) 286-4121 to speak with one of the Health Professions Student Coordinators below:

Casey Cato - ccato@midcarolinaahec.org
Sara Newton - snewton@midcarolinaahec.org

Name *

Date *

Day

Month

Year

Please Select *

Male

Female

Address *

Address (extra field)

City *

State *

Zip Code *

Phone # *

Email Address *

Emergency Contact *

Emergency Contact Phone # *

University/Department *

Degree Program *

Current year of training *

School Contact (Name, Phone #, Email)

	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Course Name and No.	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Rotation Site/ Preceptor Nameor Preferred Rotation Location(i.e. facility, city, or county preference)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Rotation Dates (Begin and End)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Do you need AHEC Housing? If yes, please indicate the housing dates (Begin and End)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)

Additional Rotation Information (ex: # of hours required, # of days per week, etc)