Student Placement for NP, PA, CNM, CRNA, AuD, Med Students & Residents

Fill out the form below on behalf of your student for consideration for student placement at an Aspirus facility. Please fill out one form per individual student.

You will be asked on the form to attest that your school or organization has an academic affiliation on file with Aspirus and has conducted a background check on the student. It is advised that you verify these things prior to starting this application, as Aspirus will not consider an application for a student of these criteria are not met. Please note that submission of this form is not a guarantee of the student's placement at Aspirus.

SCHOOL INFORMATION

* Denotes required field

• School or organization: *
• School representative first name: *
• School representative last name: *
• School representative email: *
• School representative phone:
• Instructor first name: *
• Instructor last name: *
• Instructor email:

STUDENT INFORMATION

• Student first name: *
• Student last name: *
• Student email: *
• Student Date of Birth (if known):
• Has this student has rotated with Aspirus within the last year? *

  Yes

  No

• Student city of residence: *
• Student state of residence: * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Student zip: *
• Anticipated graduation date: *
• Is student a current employee of Aspirus? *

  Yes

  No

  I Do Not Know

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PLACEMENT PREFERENCES

Select your preferred Aspirus location(s) for student placement (select as many as applicable): *

Antigo Region	Eagle River Region
Iron River Region	Ironwood Region
Keweenaw Region	Merrill Region
Medford Region	Ontonagon Region
Portage Region	Rhinelander Region
Stanley Region	Stevens Point Region
Tomahawk Region	Wausau Region
Wisconsin Rapids Region	Woodruff Region

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If placement is not possible at preferred location, is student willing to travel to an alternate Aspirus location if available?*

Yes

No

I do not know

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Student Type: * -- select -- APNP (Advance Practice NP) Audiology Certified Nurse Midwife Certified Registered Nurse Anesthetist Doctor of Medicine Doctor of Nursing Practice (DNP) DNP Leadership Non-Clinical Doctor of Osteopathic Medicine Family Nurse Practitioner Nurse Practitioner (NP) Physicians Assistant PMHNP (Psych & Mental Health NP) Resident

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• Specialty: *

  Allergy/Immunology	Anesthesiology
  Audiology	Business Health
  Cardiology	Dermatology
  DNP Leadership Non-Clinical	Emergency Medicine
  Endocrinology	Family Medicine
  Gastroenterology	Hospice & Palliative Medicine
  Hospitalist	Internal Medicine-outpatient
  Memory Clinic	Neonatology
  Nephrology	Neurology
  Neurosurgery	Obstetrics/Gynecology
  Oncology-Hematology	Otolaryngology
  Pain Management & Rehab	Pediatrics
  Podiatry	Psychiatry
  Pulmonary & Critical Care	Radiation Oncology
  Radiology	Rheumatology
  Surgery-Cardiothoracic	Surgery-General
  Surgery-Orthopedic	Surgery-Plastic
  Urology	Walk-in Clinics
  Wound Care

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• Does the student have a preceptor in mind they would like to work with? *

  Yes

  No

• Preceptor first name: *
• Preceptor last name: *
• Preceptor location: *

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• Total number of hours required to complete: *

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• Rotation start date: *
• Rotation end date: *

+ Add another rotation

INFORMATION VERIFICATION

I attest that my school or organization has an academic affiliation on file with Aspirus: *

Good standing: *

Background check: *

ADDITIONAL COMMENTS

If applicable, please provide any additional information we should know about this student:

Step 1 of 2. Next: Confirm & Submit