Request a Summer Nursing Student for a Health Care Facility

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Personal information on this form is collected under section 31(c) of the Freedom of Information and Protection of Privacy Act to register sites for the Nursing Summer Student Employment Program. If you have any questions about this collection of personal information, please call the Recruitment and Retention Secretariat at 902-620-3760.

Identification

Business/Organization Name

Contact First Name

Contact Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone 1

For example 902-555-5555

Telephone 2

For example 902-555-5555

Fax Number

For example 902-555-5555

Email Address

Supervisor Information

Provide contact details for the students' immediate supervisor if different than above.

First Name

Last Name

Telephone Number

For example 902-555-5555

Email Address