Undergraduate Student Clinical Placement Request Form

Undergraduate Student Clinical Placement Request Form
Application Form
Name of Individual Submitting Request *

First Name Last Name
Email Address *
Name of Nursing School *
Name of Clinical Instructor *
DC RN License # *
Clinical Instructor Email Address *
Clinical Instructor Phone # *
# of Students (Max 5) *
# hours per student *
# of Clinical Groups *
# of Weeks per Clinical Group *
Unit Requested

7East Medical Neuroscience Surgical Care 4 Main Heart & Kidney
Start Date for Clinical Placement Request *

Month Day Year
Date
End Date for Clinical Placement Request *

Month Day Year
Date
Day of Week Preference *
Shift Preference *
Fields marked with * are required
Should be Empty: