Affiliation Agreement Request Form

Affiliation Agreement Request Form

IMPORTANT: Do NOT fill this out if you are in the Nurse Practitioner program. Please contact your advisor for your affiliation agreement form for MSN-NP students.
Student Name

First NameLast Name
Student ID Number
Student Email
example@example.com
Select Your Program
Facility Name
Is the facility you listed part of a larger organization or facility?
Name of "Umbrella" or Main Facility
Facility Contact Name
This should not be your Preceptor unless your Preceptor has signing authority to execute legal agreements at your facility.
Facility Contact Email
This should not be your Preceptor unless your Preceptor has signing authority to execute legal agreements at your facility.
Facility Location: City
Facility Location: State
Does your facility fall under the umbrella of Kaiser Permanente?
COVID Exemptions Allowed

Other
Additional Comments or Information

For Internal Use Only