Type of Experience: *

Practice Name: *

Address: *

Telephone Number: *

Fax Number: *

Email Address: *

Website Address:

Clinical Supervisor of Elective: *

Description of Experience: *

Institutional Resources:

(Associated Veterinarians and special expertise available (postgraduate training, Specialty Board, etc.)

Educational Resources Available:

(Journals, books, computer databases, rounds, continuing education activities, etc.)

Responsibilities Expected of Participating Students: *

Student Supervision: *

(Please estimate approximate number of hours per day and days per week that the student will have directed and fredd access to veterinarians.)

Is Housing Available to the Student: *

Institution's Agreement *

I agree to accept students in future academic quarters, on a mutual consent basis between this organization and the student applying for elective quarter credit.

I agree to evaluate student performance and to report that performance back to the college within two weeks of the end of their experience.

I understand that students will evaluate their experiences in the rotation and the result of their evaluation will be available to the clinical supervisor and to additional students for consideration for future experiences.

I have AVMA or other liability insurance.

Attach a document with the above information (single .doc or .pdf file)

(The maximum size should be no more than one Mb.)

Today's Date: *

If this is a change, date of last update:

By submitting this online form, you agree that the above information is complete to the best of your knowledge. Any changes to the above information must be conveyed in writing or via this form.