Course Information: Course Number: _________ Semester: __________ Year: ________
(NP students only; check one) Rotation:
______ Primary Care/Internal Medicine
______ Geriatrics
______ Adolescent
______ Urgent Care
______ Gynecology
______ Specialty: _________________
Student Information:
Name: ________________________________________________________________________________________
Address: ____________________________________________ City: ________________________________
State: __________________ Zip Code: _____________________
Home Phone: ___________________________ Cell Phone: _________________________________
Email: _______________________________________________________
Proposed Preceptor Information:
Name & Title: __________________________________________________________________________________
Employer Name: _______________________________________________________________________________
Address: ____________________________________ City: _______________________________________
State: __________________ Zip Code: __________________ Phone: _____________________________
Fax: ________________________________ Email: _____________________________________________
Should you have any questions, please contact Deanna Kowaleski at: dkowales@emich.edu
or 734-487-6599.
To be filled out by site office manager only:
Who will sign affiliation agreement (name): ____________________________________________
Title: ________________________________________________________
Email: ___________________________________________
Phone: _________________________________ Fax: _______________________________
