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APhA-ASP SEP HOST SITE FORM 2023-2024
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* Indicates required question
Email
*
Your email
School or College of Pharmacy
*
Your answer
Host Site Location (City, State)
*
Your answer
Has your Chapter Advisor or the Dean of your school approved the creation of this host site?
*
Yes
No
Not yet, in progress.
Chapter Advisor's Name
*
Your answer
Chapter Advisor's email address
*
Your answer
Name of International Vice President
*
Your answer
Name of Local Exchange Officer (LEO)
*
Your answer
LEO's email address
*
Your answer
LEO's telephone number
*
Your answer
Have you hosted students in the past?
*
Yes
No
Number of students you anticipate hosting
*
Your answer
How long are you planning to host?
*
2 weeks
3 weeks
1 month
2 months
Other:
Anticipated Host Dates (ie: May, May-June, May-July, etc.)
*
Your answer
Pharmacy Practice Area
*
Community Pharmacy
Clinical Pharmacy - Inpatient
Clinical Pharmacy - Outpatient
Academia-related Pharmacy
Hospital or Staff Pharmacy
Research
Industrial
Managed Care Pharmacy
Other:
Required
Exchange Student Residence Address
*
Your answer
Do you have a SEP team or IPSF team ready to help you with the hosting process?
*
Yes
No
Send me a copy of my responses.
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