Student Registration Form
Return to CAMC Institute Education Portal (Back)

Assigned Clinical Education Rotation with Affiliated School


Personal Information:
If you do not have a middle name use a "-" in the Middle Initital field.

Required Field

Required Field

Required Field

Required Field

Required Field

Required Field

Required Field

Required Field

IMPORTANT: The email address submitted here must be the same as the email address used to create your account on the Education Portal.

Required Field

Required Field

Required Field

Emergency Contact Information:
(Individuals < 18 years of age must list a parent as contact.)

Required Field

Required Field

Required Field

Required Field

Where will you be assigned:
If you choose other please list the location in the field below.

Location: Selection Required

Select Your School and Program:
Your home school/program director has assigned a specific or elective rotation for which you need to register. Experience has been assigned by your home school program director. Note: If your school or program is not listed please have your instructor contact CAMC.

School/Program: Selection Required

Anticipated Date of Graduation/Completion:

Completion Date:

Duration of Experience:

Estimated # of Rotation Hours:

Required Field

Required Field

Required Field



Technical support: Monday - Friday, 8 am to 4:30 pm.
William Wallace 304-388-9994
Education Department 304-388-9960

Report problems to the Administrator. (Contact)