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PATIENT PORTALMAKE A PAYMENT SCHEDULE APPOINTMENT

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712-722-1700
877-722-1770

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care@promisechc.org

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33 4th St NW,
Sioux Center, IA

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STUDENT HOURS

HomeCAREERSSTUDENT HOURS

Fill out the form below to request student hours.

Full Name*
Phone*
Home Street Address*
City, State, Zip*
Email*
College or University Attending*
Current Year in School?*
- Freshman
- Sophomore
- Junior
- Senior
- Master's Program
Requesting student hours in what department?*
- Medical
- Dental
- Mental Health
- Social Work
List any certifications you have received
List dates/semesters you would need to get your student hours.*
example: spring semester 2025, January 20-May 1
Total hours requested*
Indicate any languages, other than English, that you are fluent in for speaking, reading or writing.
Do you know anyone at Promise CHC?*
- Yes
- No
If yes, who and what is your relationship to them?
PROFESSIONAL REFERENCE
Full Name*
Phone*
Title*
Email*
Describe your relationship to this reference*
Please specify which employee, college professor, etc that referred you.
Correct and Complete*
By checking this box and submitting this electronic application, I affirm that all of the information that I have provided in the application is correct and complete to the best of my knowledge.

33 4th St NW, Sioux Center, IA 51250
Phone: 712-722-1700
Fax: 712-722-1770
Email: care@promisechc.org

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