CoxHealth Student Learning Experience Application

Application materials are due at least 30 days prior to the scheduled start of your rotation. Submit supporting documents (see step 6) to student_education@coxhealth.com or fax to 417-269-8472.

Personal Information

1. Legal First Name *This question is required.

2. Middle initial - If no middle name, write "none" *This question is required.

3. Legal Last Name *This question is required.

4. Other Known Aliases

5. Preferred Name (If requesting a Cox Student ID badge, this is the name to be printed on your badge. E.g. Alex S. or Alex Smith) *This question is required.

6. Preferred Pronouns

7. Last 4 digits of Social Security # *This question is required. This question requires a valid number format.

8. Student ID assigned by school - include all alphabetic and numeric characters *This question is required. This question requires a valid number format.

9. Student Email Address (typically ending in .edu) *This question is required. This question requires a valid email address.

10. Preferred Email Address *This question is required. This question requires a valid email address.

11. Address *This question is required.

12. City *This question is required.

13. State *This question is required.

14. Zip *This question is required. This question requires a valid number format.

15. Phone Number (digits only) *This question is required. This question requires a valid number format.

16. Institution in which you are currently enrolled: *This question is required.

17. If "Other", please specify *This question is required.

17. Degree/Discipline in which you are currently enrolled

Students who are not actively enrolled in a healthcare program of study must contact student_education@coxhealth.com for more information regarding student experiences. *This question is required.

18. If "Other", please specify *This question is required.

18. What degree will you receive at the end of your program *This question is required.

18. Year and Semester that you enrolled in your current program. E.g. 2020 Fall *This question is required.

19. Year and Semester of anticipated graduation. E.g. 2024 Spring *This question is required.

20. Are you a current CoxHealth Employee? *This question is required.

21. CoxHealth Employee Number *This question is required.

21. Requesting Charting Access *This question is required.

22. Do you plan to park a vehicle at CoxHealth during your learning experience or clinical rotation? *This question is required.

22. Vehicle Make and Model *This question is required.

22. License Plate Number *This question is required.

Emergency Contact Information

22. Full Name of Emergency Contact *This question is required.

23. The Emergency Contact is your ____________ (ex: parent, spouse or significant other, friend) *This question is required.

24. Emergency Contact Phone Number (digits only) *This question is required. This question requires a valid number format.