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REQUEST FOR CLINICAL AFFILIATION AGREEMENT

Please provide all necessary information to expedite the process. Allow a minimum of 4 weeks for
processing. Once you finish, click submit.
 
BSN & MSN deadline for spring courses is November 1st
BSN & MSN deadline for summer courses is April 1st
BSN & MSN deadline for fall course is June 1st

 

Program/Course:  BSN 411 BSN 421   BSN 451
MSN-FNPMSN-NE MSN-NA MSN-CNL MSN-CNS

Name of Student: 

Student ID#:       

Student Phone#: 

Student Email:     

Course #:   (Example: BSN 421)   Term of enrollment for identified course:

Name of Agency:    

Address of Agency: Please type the full address here (street address, city, state, and zip)

Administrator/Chief Nurse Executive:

(Types of appropriate individuals include owner, directors of nursing, chief nurse executives and directors of education)

 Title:

Email address:

Agency Phone#:

Agency Fax#:    

Agency Website#:

If the agency participates in a placement consortium, select which one:

 Orange County/Long Beach Consortium

Central Computer Placement System (CCPS)

 San Diego Consortium

Inland Empire (San Bernardino/Riverside counties)

San Francisco CCPS

 Other  Specify