HomeAcademicsHealth SciencesElon PAPreceptor ProgramPreceptor Profile Form Preceptor Profile Form Preceptor Profile New preceptor for PA program Practice/Clinical Site Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Average number of patients per day/provider*Preceptor Name* First Last Preceptor Credentials* MD DO PA NP CNM Upload your CV/ResumeAccepted file types: doc, docx, pdf, Max. file size: 49 MB.There is a 10MB file size limit. If your CV exceeds this file size, please email to: shenderson13@elon.eduState License Number*License issue date and expiration date*Are you board certified?* Yes No If certified, year of certification and expirationSpecialty:*Preceptor email address* Preceptor phone number*How did you hear about the opportunity to precept with the Elon PA Program? (e.g., referred by a colleague, job board, social media, professional organization, Elon representative, etc.) Please specify below:If an ALUMNI of Elon PA program, enter graduation year here:Practice Setting* Family Medicine Pediatrics Surgery Inpatient Medicine Emergency Medicine Women's Health Behavioral Medicine Other ARC-PA Setting* Outpatient Inpatient Operating Room Emergency Department Additional Information Rural Location Underserved Population Availability6-week Rotation Dates for Emergency Medicine, Family Medicine, Inpatient, Pediatrics, Surgery, and Elective Rotations: Select All 2025 COHORT: Rot 4: June 2 - July 11, 2025 Rot 5: July 14 - August 22, 2025 Rot 6: September 8 - October 16, 2025 Rot 7: October 20 - December 5, 2025 2026 COHORT: Rot 1: January 5 - February 13, 2026 Rot 2: February 16 - March 27, 2026 Rot 3: March 30 - May 8, 2026 Rot 4: May 26 - July 2, 2026 Rot 5: July 6 - August 14, 2026 Rot 6: August 31 - October 9, 2026 Rot 7: October 12 - November 20, 2026 3-week Rotation Dates for Women's Health & Behavioral Health Rotations: Select All 2025 COHORT: Rot 4.A: June 2 - 20, 2025 Rot 4.B: June 23 - July 11, 2025 Rot 5.A: July 14 - August 1, 2025 Rot 5.B: August 4 - 22, 2025 Rot 6.A: September 8 - 26, 2025 Rot 6.B: September 29 - October 6, 2025 Rot 7.A: October 20 - November 7, 2025 Rot 7.B: November 10 - December 5, 2025 2026 COHORT: Rot 1.A: January 5 - 23, 2026 Rot 1.B: January 26 - February 13, 2026 Rot 2.A: February 16 - March 6, 2026 Rot 2.B: March 9 - 27, 2026 Rot 3.A: March 30 - April 17, 2026 Rot 3.B: April 20 - May 8, 2026 Rot 4.A: May 26 - June 12, 2026 Rot 4.B: June 15 - July 2, 2026 Rot 5.A: July 6 - 24, 2026 Rot 5.B: July 27 - August 14, 2026 Rot 6.A: August 31 - September 18, 2026 Rot 6.B: September 21 - October 9, 2026 Rot 7.A: October 12 - 30, 2026 Rot 7.B: November 2 - 20, 2026 Please indicate the number of students you can take for each rotation block:*How many rotations per year can you precept students?*Honorarium - Is there an honorarium for student experiences? If yes, who is the payee and what is the rate?Please identify the individual designated as Elon PA Program's point of contact for student onboarding (if other than the Preceptor)Name First Last TitlePhone(Optional) Please provide contact information for the individual who may legally sign the Affiliation Agreement for your facilityName First Last TitleEmail PhoneStudent Requirements*Elon University PA Program will submit Student Profiles when rotations are confirmed, which contain their contact information, photo, immunization records, flu, drug screen, background check, BLS, ACLS, driver's license, health insurance, and HIPAA/OSHA certification. Please list the onboarding and training requirements (in addition to what is submitted by Elon) that students will need to complete prior to being on-site:**Elon University PA Program requires background checks, drug testing, and tuberculosis screenings annually in November, please indicate only if your facility requires more frequent performance of these items.Additional FacilitiesIf a student will attend multiple facilities with you, Elon University must have a complete Affiliation Agreement with each facility. Please provide each facility's name and contact person's information so that we are able to meet this requirement prior to the student’s arrival.Name of Facility, Type of Facility, Contact Person's Name & Email Address. Enter as many as applicable:*Please enter any additional information you would like to share:Thank you!We appreciate the opportunity to partner with you in the education of our students!CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.