Type your application & include your name and academic institution in the file name. Email completed request form to your Academic Placement Coordinator. Note that this form will be shared with SickKids educators and potential preceptor(s) as part of the placement request process. Applicant Personal Profile Salutation: Last Name: First Name: Telephone: Email: Placement Coordinator Course Instructor Name: Name: Email: Email: Telephone: Telephone: Academic Profile Academic Program Applicant’s School Name: NICU Certificate: School Address: CCU Certificate: OR Certificate: Continence Certificate: Ostomy Certificate: Other Certificate: RN Refresher: Duration of Placement - please specify EXACT start and end date Start Date: End Date: Requested Clinical Area - please indicate your choice from the drop down menu 1. Additional Applicant Information please check as many boxes as apply Prior Paediatric Experience: Employment School Rotation Where/When: Prior/Current Employment at SickKids: RN Other When: Current Certification: RN Other:
Type your application & include your name and academic institution in the file name. Email completed request form to your Academic Placement Coordinator. Note that this form will be shared with SickKids educators and potential preceptor(s) as part of the placement request process. Applicant Personal Profile Salutation: Last Name: Telephone: First Name: Email: Placement Coordinator Course Instructor Name: Email: Telephone: Name: Email: Telephone: Applicant’s Academic Profile Academic Program School Name: School Address: NICU Certificate: CCU Certificate: OR Certificate: Continence Certificate: Ostomy Certificate: Other Certificate: RN Refresher: Duration of Placement - please specify EXACT start and end date Start Date: End Date: Requested Clinical Area - please indicate your choice from the drop down menu 1. Additional Applicant Information please check as many boxes as apply Prior Paediatric Experience: Employment School Rotation Where/When: Prior/Current Employment at SickKids: RN Other When: Current Certification: RN Other: