EMS Student Clinical Request

Student Information

First Name (Legal Name)

Last Name (Legal Name)

EMS Class/Location

Email Address

Phone

I have completed the Computer Based Learning, required for any student on site at Memorial Health.

Requested Area (Please select from the list below)

Date

Start Time

Stop Time

I am flexible regarding this day, but the times indicated reflect the number of hours I hope to schedule.

Add another request at this time.

Requested Area (Please select from the list below)

Date

Start Time

Stop Time

I am flexible regarding this day, but the times indicated reflect the number of hours I hope to schedule.

By submitting this request, I the EMS Student, am available at the above date and time and am requesting to be scheduled for clinical. Requests will be processed in the order received. Please allow 1-3 days for requests to be scheduled. Should your availability change after the request was submitted, you are expected to email MemorialEMS@mhsil.com to cancel your request.

You will receive an email confirmation when your clinical is scheduled. This will include directions regarding parking, signing in and location of your request. Upon receipt of that email you are scheduled and expected to attend the assigned clinical. Cancelations, or failure to attend, should be the very rare exception.