Thank you for your interest in becoming a student at Montgomery County Memorial Hospital + Clinics. Please complete the form below to proceed.

Please download these 3 documents, complete the required fields, and SAVE to your device prior to submitting the form. You will be required to upload the completed forms on this page prior to submission.

Student Name

Phone Number

School/Institution

Program Type

School Point of Contact - Name

School Point of Contact - Email

Type of Request

Specialty/Department Requested

Specific Provider Requested

Start Date Requested

End Date Requested

Total Hours Required

Any other information we should know:

Montgomery County Memorial Hospital (MCMH) requires an active affiliation agreement with the educational institution for all student clinical experiences.

Affiliation Agreement Status

Active

Needs Agreement

Unsure

Please provide a contact from your school that we can reach out to, to obtain this agreement. We must have this prior to your starting.

Please check box to confirm your understanding:

I understand submission does not guarantee placement.

Please check box to confirm your understanding:

I understand all required records and forms must be provided before placement will be considered.

Please check box to confirm your understanding:

I understand documentation must be approved before placement begins

Please check box to confirm your understanding:

I will be notified via email if placement is accepted or denied.

Required Records Upload

From Previous Download Buttons at Top of Form:

MCMH Corporate Compliance Training Acknowledgement

Confidentiality Acknowledgement

Laptop Agreement

If you are a Clinical Rotation / Preceptorship Student all below records must be emailed prior to the consideration of this request to students@mcmh.org

- Immunizations
- TB screening (within last year)
- Influenza Vaccine (from current or most recent influenza season) or Declination Form

All forms must be signed and uploaded prior to submission of this request.