Request for Individual Student Placement

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Undergraduate Pre-Licensure Student Graduate Nursing Student

Student Name

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Home Address

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City

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State

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Zip Code

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Email Address

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Home Phone

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Cell Phone

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Affiliate School

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Other

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(an active affiliation agreement for school/program must be confirmed before placement consideration)

Program of Study

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Other

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School Contact Person

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Title

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Phone Number

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Fax Number

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Email Address

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Request dates to begin clinical

From

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Preceptor's Name

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Phone

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Site/Unit

Please Enter First Choice Unit

Total number of clinical hours needed

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Preferred Site

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Department manager

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Is student a virtua employee

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

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

First objective

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Second objective

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Third objective

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Fourth objective

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

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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.