Student Affiliate Individual

Profile

Undergraduate

Pre-Licensure Student

Graduate Nursing Student

Student Name

Home Address

City

State

Zip Code

Email Address

Home Phone

Cell Phone

Affiliate School

Other

Program of Study

Other

School Contact Person

Title

Phone Number

Fax Number

Email Address

Request dates to begin clinical

From

To

Preceptor’s Name

Email

Phone

Site/Unit

Total number of clinical hours needed

Preferred Site

Department manager

Is student a virtua employee

Yes

No

For RNs Does the student have a New Jersey nursing license?

Yes

No

Identify specific objectives you wish to accomplish with this learning experience. (Minimum of three is required)

First objective

Second objective

Third objective

Fourth objective:

Attach Resume Document (Must be less than 5mb and Word or PDF file)

Comments

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Request for individual student placement

Warning: This form must be completed by a student enrolled in an educational program or authorized personnel representing an academic institution affiliated with Virtua.