THM Externship Request Application – INSTITUTE OF TRADITIONAL MEDICINE

THM Externship

Please submit this form if you intend to complete your 2nd Year clinical hours as an Externship.

Please ensure you have all first year requirements met and are not in default of any tuition fees or course requirements.

*All requests for Externships must be reviewed and approved by ITM Faculty.

***Upon acceptance of your Externship request, you will be notified by email.

Student Name *

First

Last

Email *

Phone *

Which Term in Year 2 are you applying to complete your Externship *

Fall
Winter
Spring
All Terms in Year 2

What is the method of Supervision *

In-Person on-site location
Online - via Zoom
Combination of in-person/online

Do you currently have insurance (malpractice - errors/omissions)? *

Yes
No
No, will purchase prior to Externship

Name of Potential Clinical Supervisor *

First

Last

Brief Educational Background and Clinical Experience of Supervisor (Including # of years in Practice, Clinical Location) *

Location of Externship if In-Person Onsite (or Location of Supervisor Clinic) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Personal Reflection of Intent * Please share a few words on why you feel an Externship would benefit your learning/practice. *

Additional Info (any information regarding your request to complete an Externship)

Declaration *

Agreed

By checking this box and submitting this application request to complete an Externship, I acknowledge and agree to the following: *All information filed during this application process become part of your permanent, confidential record. Declaration: I hereby attest that all statements on this application form are true and complete in all respects, and no relevant information has been withheld. I agree and abide by the policies, rules and regulations of the Institute of Traditional Medicine. I agree that I have fully reviewed the THM Externship Document outlining the requirements of an Externship and understand that a failure to meet all requirements may result in a non-transfer of any externship clinical hours.

Waiver *

Agreed

By checking this box and submitting this application/registration I acknowledge and agree to the following: I, the participant release the organizers of the training and their directors, sponsors, employees and agents from any liability for death, disability, injury and property damage. The participant acknowledges the risks involved with participating in an Externship and assumes all responsibility, and waives any claims they may have. The participant agrees that they have informed the organizers of any relevant medical (health or mental) concerns that they may have or any concerns about a potential Supervisor they may have. *I am acknowledging that I have read, understand and agree to the refund and cancellation policies and waiver, and understand and agree that ITM is not responsible for any Externship financial obligations.