Student Profile for Preceptor Program

The Preceptor Program is designed as a voluntary peer support program for students entering SJC. Preceptors facilitate the development of students entering the nursing profession through student guidance. Incoming students will be mentored by senior students.

In order to match incoming students with the best possible mentor, please complete the profile below. If you choose not to participate, please indicate by signing at the bottom of this form.

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* 1. Name

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* 2. Which program will you be in?

Accelerated program

Traditional (General) Program

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* 3. Summer Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 4. Do you have your Bachelor's?

Yes

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* 5. Do you plan to work while in school?

Yes

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* 6. Living Independently?

Yes

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* 7. Are you married?

Yes

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* 8. Do you have any children?

Yes

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* 9. Do you live in:

Springfield

Out of town

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* 10. How do you study?

Alone

With others

Alone AND with others

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* 11. What is your go-to study snack?

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* 12. Fun fact about you:

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* 13. Hobbies/Interests:

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* 14. Professional goals in nursing:

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* 15. If you know a current SJC student with whom you would like to be paired, please list their name

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* 16. I understand this information will be used to match me with a senior student who has similar information and can assist me as I transition to nursing school. Would you like to participate in the Preceptor Program?

Yes