APRN Application

Part 1: To Be Completed By Applicant (use one form for each requested clinical experience)

First Name *

Middle Initial

Last Name *

Date of Birth *

Last 4 digits of SSN *

CURRENT LOCATION

Home Address *

Address Line 2

City *

State *

Zip Code *

Daytime Phone *

Cell Phone: *

Email Address *

Are you fluent in Spanish? *

Yes

No

Are you a MetroHealth Registered Nurse? *

Yes

No

If yes, what is your employee ID number?

OHIO LICENSE INFORMATION

RN License Number *

CURRENT SCHOOL INFORMATION

School Name *

Part 2: I Would Like to Apply for the Following Semester and Year

Semester *

Fall

Spring

Summer

Year *

Date Clinicals Will Begin * +

Date Clinicals Will End * +

Number of Clinical Hours Required *

Projected Degree Specialty *

Anticipated Enrolled Class During Clinical Experience *

How many semesters have you completed in the APN program? *

Type of clinical experience being requested *

Name of approved MetroHealth preceptor * 🛈

Part 4: Faculty Contact Information

The above-named is a student in good standing at this institution. Malpractice insurance covers the student away from this school. The student is authorized to participate in this clinical experience.

The student is in year *

School/Clinical Coordinator Name *

Email Address *

Phone *

Your school will need to send a letter of verification of the following:

The student is an APRN student in good standing
The student possesses an unencumbered and current Registered Nurse License in the state of Ohio
Possesses a current BLS certification
Has a valid and clear background check on file at the school
Has appropriate malpractice and liability insurance
Has up to date vaccinations including TB and influenza vaccine (Nov-Apr)

Please have your school send a signed verification letter from the APRN program director attesting to all items above.