WVU School of Dentistry

Dental/Dental Hygiene Student Rural Practice Placement Request Form

This form must be completed to request a RHEP site. Every effort will be made to honor your 1st choice. However, if scheduling conflicts occur due to limited capacity of if the overall goals of the program(s) are not being addressed, other assignments may be made. Assignments other than one of these selections will be discussed with you before being finalized.

Name:
Phone Number(Home) :
Phone Number(School) :
Address: (Where rural site faculty and site coordinators can correspond with you)
E-mail Address : (Must be filled in)
9 Digit student ID Number: (Must be filled in for online evaluation identification)
Click here if left-handed: (Left-handed students must select from the bolded sites)	Left Handed
No site preference: (Assign me to the best available site)	No Site Preference
Gender: (For housing purposes only)	Male Female
1st Choice:
Site/Dentist's Name:
Reason(s) for choosing this site :
Housing Request:	Yes No
2nd Choice:
Site/Dentist's Name:
Reason(s) for choosing this site :
Housing Request:	Yes No
3rd Choice:
Site/Dentist's Name:
Reason(s) for choosing this site :
Housing Request:	Yes No

Gender:	Male Female
Date of Birth :
Racial/Ethnic Background:	American Indian or Alaska Native African American/Black Caucasian/White Hispanic or Latino Asian (Chinese, Filipino, Japanese, Korean, Thai) Asian (from a country other than those listed above) Native Hawaiian or Other Pacific Islander
Do you consider yourself to have ever been from an economically or educationally disadvantaged background?:	Yes No

*Each individual student is required to submit a Project Protocol. Do not assume since a partner or other member(s) of a group have submitted a Project Protocol that you are exempt. Failure to submit an individual Project Protocol will affect your first-semester grade.