Nurse Practitioner Student Clinical Application

Name*

First Last

Prefix*

Email*

(Please use your school or personal email address.)

Number of years as an RN?*

Please enter a number from 0 to 100.

Are you a Mercyhealth partner?*

Yes
No

Employment status*

FT
PT
PRN

Department / Unit Employed*

College / University*

Degree Program*

Current or Undergraduate GPA

Expected Date of Graduation (MM/YY)*

Please provide a brief description of your RN practice experience. Please do not reference "see resume".*

Upload Resume*

Accepted file types: doc, docx, pdf, Max. file size: 75 MB.

Provide current resume or CV. This will be included in the packet that is provided to the departments.

Upload Letter of Introduction*

Accepted file types: doc, docx, pdf, Max. file size: 75 MB.

Provide letter of introduction. This will be included in the packet that is provided to the departments.

Upload Clinical Objectives*

Accepted file types: doc, docx, pdf, Max. file size: 75 MB.

Provide documentation of clinical objectives you would like to achieve as part of this rotation.

Session Request

Please choose the session that best aligns with your clinical request needs. Applications submitted after the semester deadline date will not be considered for placement. Due to the high demand for placement, no exceptions will be made.

Session*

Start Date*

End Date*

Total Number of Hours Required for this Semester*

Preferred # of Hours / Week*

Preceptor Requirement (check all that apply)*

APN
MD/DO
PA

Clinical Rotation*

Inpatient
Outpatient

Clinical Location (check all that apply)*

Rock County, Wisconsin
Walworth County, Wisconsin
McHenry County, Illinois
Winnebago County, Illinois

Department(s) (You may enter multiple department requests if needed or an alternate need within the requested session.)*

What do you believe will be your preferred specialty area upon completing your advanced practice nurse program requirements? Please choose from the following specialty areas.

Specialty Area 1st Choice*

Specialty Area 2nd Choice*

Please provide a contact at your school of nursing to facilitate coordination of the clinical placement

Name*

First Last

Email*

Phone*

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Phone

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