Student Placement Application Form | Reconnect Community Health Services

Student Placement Application Form

Name:

Address:

City:

Province:

Postal Code:

Phone:

Email:

Status in Canada:

Educational Institution:

Program of Study:

Degree/Diploma/Certificate to be granted:

Year of Study:

Expected Date of Completion:

Professional Body Affiliation (if any):

Practicum Start Date:

Practicum End Date:

Number of Hours Required:

Student Preceptor Perquisites set out by your Educational Institution:

Academic Contact Name:

Academic Contact Phone:

Academic Contact Email:

Please describe any relevant experience you have obtained thus far:

Please outline your practicum objectives/goals and interests:

Please indicate the top three programs that are of interest to you in priority order (i.e. first choice, second choice, third choice):

Please attach your cover letter in Microsoft Word of PDF format

Please upload Resume in Microsoft Word or PDF format