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.

1. Student Name: ___
2. Student Mailing Address: _____
3. Agency Name: ___
4. Agency Contact Person: ___
5. Type of Agency (clinical, hospital, etc.): ___
6. Email Address: ___
7. Agency Address: ___
8. City:_____State:_____ZIP:
9. Phone Number: ___
10. Preceptor Name: ___
11. Preceptor Credentials: ___
12. Specialty Area: ___