Children's Hospital of The King's Daughters Health System

Note: Required fields are marked with an asterisk (*)

Contact Information

First Name: *

Last Name: *

Address *

City *

State

Zip Code *

Phone Number *

Email *

Education Information

Current Level of Education
School or University Attending
Are you applying into a therapy program at a college or university?	Yes No
If yes, are you interested in pursuing a career in?	Occupational Therapy Physical Therapy Speech Language Pathology Other
If Other?

Observation Information

Desired start date?

Open the calendar popup.

Please indicate the number of observation hours you are requesting:

0-10hours
10-20hours
20-30hours
40-or more hours

Please list the days of the week, as well as time of day, you would are available to complete observation hours.

Monday
Tuesday
Wednesday
Thursday
Friday

A.M. (8am-12pm)P.M. (1pm-6pm) A.M. (8am-12pm)P.M. (1pm-6pm) A.M. (8am-12pm)P.M. (1pm-6pm) A.M. (8am-12pm)P.M. (1pm-6pm) A.M. (8am-12pm)P.M. (1pm-6pm)

What site(s) would you prefer to observe at?

CHKD Hospital at NorfolkCHKD Medical Tower at NorfolkCHKD Health Center at Harbor View
CHKD Health Center at OakbrookeCHKD Health Center at KempsvilleCHKD Health and Surgery Center at Princess Anne
CHKD Health Center at General BoothCHKD Health Center at Burnetts WayCHKD Health and Surgery Center at Oyster Point
CHKD Medical Tower at Norfolk

Please provide us information regarding why you would like to obtain observation hours in the Therapy Services Department at CHKD:

Please provide any specific requests you have regarding observation hours at CHKD