Application for NC AHEC Program Community Primary Care Rotation

To: Greensboro AHEC OPRCE

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

1200 N Elm St., Greensboro, NC 27401
Fax: 336.832.3570

ORPCE Student Housing Contacts:

All requests for housing must be completed online by logging into your MyAHEC account at and selecting "Request Housing" under the "My Tools" tab. A completed Housing Agreement Form and a $50.00 security deposit are required. Complete details and payment instructions are available at Deposits are forfeited for no-shows or cancellations without a 72-hour notice. Counties served are Alamance, Caswell, Chatham, Guilford, Montgomery, Orange, Randolph, and 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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