STUDENT / RESIDENT FACT SHEET

St. Claire Regional Credentialing Packet for Nursing Students

I. DEMOGRAPHICS
First Name:
MI
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Date of Birth:

MonthDayYear
Date
Last 4 digits of SS #:*
Student ID #:*
Gender:

MaleFemale
Discipline:
II. ROTATION
Preceptor:*
Rotation Site:*
Health Discipline:*
Start Date:*

MonthDayYear
Date
End Date:*

MonthDayYear
Date
Graduation Date:*

MonthDayYear
Date