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 *
In Patient Unit Requested

7East Medical Neuroscience Surgical Care 4 Main Heart & Kidney
Clinic Requested

Specialty Clinic Rotation (5 students per day) Columbia Heights ( 2 students per day) Montgomery County Regional Outpatient (2 students per day) Friendship Heights Regional Outpatient Clinic (1 student per day) Complex Care Shepard Park (4 students per day)
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: