2017 Summer Student Nurse Externship -School of Nursing Application

2017 Summer Student Nurse Externship - School of Nursing Application

Please complete the 2017 MS Summer Student Nurse Externship Program School of Nursing Application by entering your information into the fields below.

If you have questions, or if additional follow up is needed, please contact Monica Nguyen, Project Manager, MHA Health, Research, and Educational Foundation | mnguyen@mhanet.org | (601) 368.3321

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* 1. Identify the school of nursing that is applying to participate in the MS Student Nurse Externship Program.

Name of School

Address

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* 2. Will your school of nursing offer a Summer Student Nurse Externship course during the Summer 2017 term?

Yes

If NO, please indicate reasons. If YES, please answer questions 2-6.

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* 3. What is the title of the course?

Question Title

* 4. How many credit hours will be given for the course?

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* 5. How many students can you admit to the course?

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* 6. Provide the following information for the faculty serving as the primary contact person for the course. If your school offers the externship course from more than one site (campus), please provide a contact person's name for each site.

Name for contact #1

Email for contact #1

Phone for contact #1

Name for contact #2

Email for contact #2

Phone for contact #2

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* 7. Please send a copy of the course description and syllabus to Monica Nguyen, Project Manager for MHA Health, Research, and Educational Foundation mnguyen@mhanet.org. If you have questions, and need Dawn to follow up with you, please provide your contact information below.

Name

Phone Number