Nursing Student Placement Request Form

for INPATIENT UNITS

Please type your application
Email completed requests to your Placement Coordinator

Applicant Personal Profile

Salutation: Choose an itemMrMrsMs
Last Name: Click here to enter text
Telephone: ()--
/
First Name: Click here to enter text
Email: Click here to enter text

Nursing Student Placement Request Form

for INPATIENT UNITS

Placement Coordinator / Course Instructor
Name: Click here to enter text
Email: Click here to enter text
Telephone: ()- -
/ Name: Click here to enter text
Email: Click here to enter text
Telephone: ()- -
Applicant’s Academic Profile / Academic program
School Name: Click here to enter text
School address: Click here to enter text
/ BScN (4yr): 3rd4th
BScN (2yr): 1st 2nd
BScN Post RN:
RN Refresher:

Duration of Placement – please specify exact start and end date

Start Date:MM - DD - YYYY / End Date: MM - DD - YYYY

Applicant’s Unit Placement Requests – please indicate your 1st, 2nd, and 3rd choices only

Please note that for placements in the ED, CCU, NICU, PACU, 6A you must have completed a placement in an acute paediatric care setting.

1st choice:

2nd choice:

3rd choice:

Additional Applicant information – please specify exact start and end date

Prior Paediatric Experience:
Employment School Rotation
Where/When: Click here to enter text

Prior/Current Employment at SickKids:
Clinical Extern Unit Clerk Other
When: Click here to enter text

Current Certification:
RN RPN Other: Click here to enter text

SickKids Student Tuition Bursary Award Recipient:
No Yes
if yes, when: Click here to enter text

Outline why you are interested in the practice area or initiative(s) that you are applying for (point form, 700 characters max):

Click here to enter text

Identify your past work, life, volunteer and/or academic experiences that are relevant to the placement that you are applying for (point form, 700 characters max):

Click here to enter text

Identify your learning objectives for the placement (point form, 600 characters max):

Click here to enter text

Identify your previous clinical placements (point form, 500 characters max):

Click here to enter text

Placement Coordinator/ Instructor/ Professor use only
I have reviewed this application and I agree with the applicant’s choices for placement and the information supplied. The student demonstrates the requisite knowledge skill and judgement for the requested placement areas. The student has strong academic and clinical performance (a minimum of a B average).
If applicable, please indicate the placement days per week:
Mon Tue Wed Thu Fri Sat Sun
Total Hours for Clinical Placement:Click here to enter the value
Name of Placement Coordinator:Click here to enter text
Please email completed form to