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Application for Advance Practice Nursing Students

  

Part I: TO BE COMPLETED BY APPLICANT (USE ONE FORM FOR EACH REQUESTED CLINICAL EXPERIENCE)

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Last Name:
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First Name:
Middle Initial:
*
Date of Birth:

Current Location

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Number and Street:
*
City:
*
State:
*
Zip:
*
Daytime Phone:
Cell Phone:
*
E-mail Address:
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Are you fluent in Spanish?
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Are you a MetroHealth Registered Nurse?

Permanent Location

Number and Street:
City:
State:
Zip:
Phone Number:
Fax Number:

Ohio License Information

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RN License Number:
*
Expiration Date:

Current School Information

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School:
Address:

PART II: I WOULD LIKE TO APPLY FOR THE FOLLOWING SEMESTER AND YEAR

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Semester:
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Year:
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Date Clinicals Will Begin:
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Number of clinical hours required:
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Projected Degree Specialty:
(ex. Family Practice NP)
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Anticipated enrolled class during clinical experience:
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How many semesters have you completed in the APN program?
*
Type of clinical experience being requested:
(ex. 60 hrs. Pediatric, 60 hrs. Adult)
*
Name of MetroHealth preceptor:

(Name of MetroHealth preceptor is REQUIRED.

Please contact them and have approval
from them before completing the form.)  Name of Preceptor is required.
Not accepted N/A, None or Unknown.

Month and year preceptor information required by your school for this experience (If no set time, enter n/a):

PART III: LIST ALL APN STUDENT CLINICAL EXPERIENCES AND ALL PROFESSIONAL NURSING EXPERIENCES

APN Student Clinical Experiences:
Location Completed:
Dates:
Professional Nursing Experience:
Employer:
Dates:

PART IV: FACULTY CONTACT INFORMATION

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The above named is a student in good standing at this institution. 
Malpractice insurance cover the student away from this school.  
The student is authorized to participate in this clinical experience. The student is in year:
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Name:
Title:
Date:
*
Phone:
E-Mail Address:

Student's evaluation should be sent to:

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Name:
*
Number and Street:
*
City
*
State:
*
Zip:

Your school will need to send a letter of verification of the following:

  • The student is an APRN student in good standing
  • The student possesses an unencumbered and current Registered Nurse License in the state of Ohio
  • Possesses a current BLS certification
  • Has a valid and clear background check on file at the school
  • Has appropriate malpractice and liability insurance
  • Has up to date vaccinations including TB and influenza vaccine(Nov. – April)

 Please have your school send a signed verification letter from the APRN program director attesting to all items above.

Please upload your school verification letter and immunization records here.  You will not be permitted to start your clinicals until an application is complete, a verification letter and immunization records are uploaded.

Upload Attachment 1:

(Allowed extensions: *.doc, *.docx, *.pdf, *.txt, *.xls, *.xlsx)
Upload Attachment 2:
(Allowed extensions: *.doc, *.docx, *.pdf, *.txt, *.xls, *.xlsx)
Upload Attachment 3:
(Allowed extensions: *.doc, *.docx, *.pdf, *.txt, *.xls, *.xlsx)
© Copyright 2002 - The MetroHealth System|2500 MetroHealth Drive|Cleveland, OH 44109|(216) 778-7800|All Rights Reserved.
  • © Copyright 2002 - The MetroHealth System
  • 2500 MetroHealth Drive|Cleveland, OH 44109|(216) 778-7800
  • All Rights Reserved.