NC AHEC Program Community Primary Care Rotation Application

To: Greensboro AHEC OPRCE

AHEC/Office of Regional Primary Care Education (ORPCE) Information

1200 N Elm Street, Greensboro, NC 27401 Fax: 336-832-3570

Contacts:

All housing request must be completed online at www.myahec.net A Housing Agreement Form and $50.00 security deposit required. View www.gahec.org for details and payment instructions. Deposit forfeited for no-shows or without 72-hour cancellation. Counties served: Alamance, Caswell, Chatham, Guilford, Montgomery, Orange, Randolph, Rockingham

Please complete the following information.












(if placement has not been scheduled)


Student/Course Information:
I verify that this student is in good standing with the University, has completed all pertinent OSHA training, and is covered for liabitility during this community rotation.
Placement Information:
We request that the AHEC/ORPCE office assist with this student placement.
We have tentatively scheduled the above student with the following preceptor:
Please include full address: street, city, state, and zip
AHEC Housing


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