Progressus Therapy > Student Info > Externship & Fieldwork

First Name:*

Last Name:*

Address:*

City:*

State:*

Zip Code:*

Telephone:*

Email Address:*

University:*

Anticipated Graduation
Month:*

Anticipated Graduation
Year:*

Academic Rank:*

Undergrad
First Year Grad Student
Second Year Grad Student
Other

Discipline:*

Occupational Therapist
Physical Therapist
Speech-Language Pathologist

Course Requiring
Externship:*

Desired Start Date:*

(Month/Year)

Desired Completion Date:*

(Month/Year)

Desired City
First Choice:*

Desired State
First Choice:*

Desired City
Second Choice:*

Desired State
Second Choice:*

Select One:*

Observation
Field Experience
Level I Fieldwork Placement (For OTs)
Level II Fieldwork Placement (For OTs)
Internship/Externship

Faculty Name:*

Faculty Phone:*

Faculty Email:*

Experience or Hours
Seeking:*

How did you hear
about us?:*