Internship Request 2025 Dental Office Contact InformationPlease state the contact information for the point of contact for this location. Dental Office(Required) Type of Office Office Contact Name(Required) Title(Required) Contact Email Address(Required) Email Address Confirm Email Phone(Required)Office Address(Required) Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Hours AvailablePalomar College Dental Assisting interns are assigned three days per week except on January 22-31 during the winter intersession. Please indicate the times they will be expected to start work, when your office has a scheduled lunch break, and the time your office closes. NOTE: Students must be dismissed by 7pm. For Session I, January 22 to 31, the student will directly coordinate with you in completing the 50 clinical hours they need. The rest of the schedules will be done Mondays, Tuesdays and Thursdays.Monday Hours(Required)Start Time (ex. 8 AM)Lunch Break (ex. 12-1 PM)End Time (ex. 5 PM)Tuesday Hours(Required)Start Time (ex. 8 AM)Lunch Break (ex. 12-1 PM)End Time (ex. 5 PM)Thursday Hours(Required)Start Time (ex. 8 AM)Lunch Break (ex. 12-1 PM)End Time (ex. 5 PM)Sessions AvailableThree sessions are available to host Palomar College Dental Assisting interns. Please indicate which session(s) and the number of interns your office can accommodate.Session Dates(Required)(These are tentative dates and might change nearing the start of the Sessions) Session I: January 22 – January 31 / February 3 – February 14, 2025 Session II: February 18 – March 21, 2025 Session III: March 31 – May 3, 2025 Select All# of Interns for Session I(Required)January 22 – 31, 2025 Schedule(Required) I understand that students will directly coordinate with the office for the schedules to meet the 50 hours requirement.# of Interns for Session II(Required)# of Interns for Session III(Required)Does your clinic require the student to submit any forms or documents? Ex. Proof of immunizations, etc.(Required) Yes No Please list your requirements below(Required) Δ
