BETTY WHITE HEALTH CENTER
Graduate Nursing Program
Adult-Gerontology Primary Care DNP Program
Request to Establish an Affiliation Agreement
To initiate the affiliation agreement process, complete and submit this form to the Director of Graduate Nursing Programs.
Student Name: ___
Student Mailing Address: _____
Agency Name: ___
Agency Contact Person: ___
Type of Agency (clinical, hospital, etc.): ___
Email Address: ___
Agency Address: ___
City:_____State:_____ZIP:
Phone Number: ___
Preceptor Name: ___
Preceptor Credentials: ___
Specialty Area: ___