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Health Care Talent Innovations: Withdrawal Request

Van Thanh Tran submitted a withdrawal request form from the Clinical Care Extender Internship program at St. Mary Medical Center. The form requests information such as name, contact details, internship details, reason for withdrawal which is noted as enrolled in health professional school, and a statement acknowledging the internship hour requirements and process for returning property. It also provides information about staying connected to the alumni network for career and networking opportunities. The form is to be processed and checklist items completed including updating the applicant's status in records, collecting the ID badge, and notifying the relevant departments.

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62 views1 page

Health Care Talent Innovations: Withdrawal Request

Van Thanh Tran submitted a withdrawal request form from the Clinical Care Extender Internship program at St. Mary Medical Center. The form requests information such as name, contact details, internship details, reason for withdrawal which is noted as enrolled in health professional school, and a statement acknowledging the internship hour requirements and process for returning property. It also provides information about staying connected to the alumni network for career and networking opportunities. The form is to be processed and checklist items completed including updating the applicant's status in records, collecting the ID badge, and notifying the relevant departments.

Uploaded by

AnnTran
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HEALTH CARE TALENT INNOVATIONS

WITHDRAWAL REQUEST
All form fields are required. The form will not be processed if any of the fields are incomplete. Write N/A if not applicable

FULL NAME:

Van

Thanh

Tran

FIRST

MIDDLE

LAST

[email protected]

(714) 596-2302

(714) 658-3834

E-MAIL

HOME PHONE

CELL PHONE

WORK PHONE

ADDRESS:

17242 Santa Clara

Fountain Valley

CA

92708

Permanent

STREET

CITY

STATE

ZIP

STREET

CITY

STATE

ZIP

ADDRESS:
Local

INTERNSHIP PROGRAM: Clinical Care Extender Internship


INTERNSHIP SITE:

St. Mary Medical Center

Please check here if your information has changed since your entry into the program

PLEASE READ AND SIGN THE FOLLOWING STATEMENT:


I understand that I am free to end my commitment as a Volunteer Intern at any time during my internship. However, if I wish to return, I
understand that I will be held accountable for the required 280 graduation hours, which includes serving additional 120 floor hours regardless
of the amount of floor hours accumulated prior to the withdrawal. By withdrawing, I acknowledge that I am ineligible to receive a Letter of
Recommendation unless I meet the aforementioned requirements. I agree to return my badge and any other property belonging to the
Internship Site, as well as complete the required exit survey. I understand that I am entitled to an Hours Audit documenting total hours
accumulated; however, failure to adhere to these guidelines and return this signed form will result in my hours not being reportable. If this
procedure is followed properly, I may elect to remain engaged in the Alumni Network and receive annual updates about specific events that will
assist me with my professional and personal goals.

Van Thanh Tran

02/16/13

SIGNATURE (Type your full name if submitting electronically)

MM/DD/YY

CURRENT DEPARTMENT

Please check here if you are in the accelerated program

PLEASE INDICATE YOUR REASON FOR WITHDRAWAL:


Found another program
Personal
Loss of interest
Hired by COPE Health Solutions

Moved away
Time commitment too great
Change in career goal
Enrolled in health professional school

Medical
Travel distance too far
Hired by the Internship Site
Other

If Other please explain:

*If you would like an Hours Audit , please submit a completed Audit Request Form.

STAY CONNECTED:

Reconnectwithcolleaguesandbuildastrongprofessionalnetworkofpeersforlife
Discovercareerandnetworkingopportunities
Receivea1050%discountonPrincetonReviewTestPreparationcourses
Connect,collaborateandinnovatewithpeerswhohavesimilarinterests
Attendeducationalandsocialeventsthatenablelearningfromexpertsandthoughtleaders
Getmentoringandsupporttobecomeatophealthcareprofessional
Receiveaccesstoquarterlynewsletterandsocialmediasites

http://www.copehealthsolutions.org/alumni
OFFICE USE ONLY
DEACTIVATION CHECKLIST:
(Check when completed)
INTERNSHIP START DATE:

Received Completed Withdrawal Form


MM/YY
Confirm status with respective supervisor
(If Applicable)

INTERNSHIP END DATE:


MM/YY

VERIFIED BY:

Update SQL information


Status: Inactive
Withdrawn
Date Withdrawn
Withdrawn Status

Returned ID
Badge
Completed Exit
Survey

CCE NOTIFIED ON:


NAME

SIGNATURE

MM/DD/YY

MM/DD/YY

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