Adult hugging smiling child wearing yellow flower shirt.
Specialty care
made personal.

Clinical Experience Request Form

Submit this form to request a learning experience at a location in the Northwest Wisconsin region of Mayo Clinic Health System.

Contact Medical Education at mchsnwwisturot@mayo.edu, or call 715-464-2224 with questions about completing the form or the program.

If submitting this form on a laptop or desktop computer, use Google Chrome or Microsoft Edge, as other browsers are not supported. Be sure to follow the instructions and hints provided. You'll receive a confirmation page and email if the form has been successfully submitted. If you don't receive a confirmation, try clearing your browser, and completing and submitting the form again.

NP and PA students: Do not submit this form. Visit the Nurse Practitioner Clinical Education Collaboration Program website or Physician Assistant Clinical Rotation Program website for rotation opportunities.

Personal Information
Use your legal first name.
Use your legal last name.
Use 5-digit ZIP code
(Please use format mm/dd/yyyy)
Maximum length of 1,500 characters.
School Information
Use 5-digit ZIP code
Clinical Experience Information
Maximum length of 1,500 characters.
Maximum length of 1,500 characters.
Maximum length of 1,500 characters.
Maximum length of 1,500 characters.
Program Information (non-Mayo Clinic employee)
Emergency Contact Information
Maximum length of 1,500 characters.