Internship Request 2025 Dental Office Contact InformationPlease state the contact information for the point of contact for this location. Dental Office(Required)Type of OfficeOffice 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 Does your office have an RDA on staff? Yes No Hours AvailablePalomar College Dental Assisting interns are assigned Monday, Tuesday and Thursday every week between January 17th and May 16th, except the first two weeks students will intern Monday through Friday. 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 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.# of Interns for Session I(Required)January 17- 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