Student Application for Preceptor Clinical

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pre-requisites for clinical

date *

YYYY

Your Full name

Email Address

Address

Nursing Title

Nursing Registration number

Dates you completed Foot Canada Theory Program *

Please provide some information to help streamline the application process *

I do not have a preceptor at this time.

I have a preceptor

Required

Preceptor Full Name

I agree to provide the following documents prior to the start of my Preceptor clinical foot care course and I understand that I cannot proceed with the clinical course if I fail to provide these documents: *

No refunds for tuition will be issued for failure to provide these documents on time. Documents should be provided as early as possible.

Proof of FCN Theory Completion. Email the certificate.

Current Government-Issued Photo ID. Email A picture of driver's license or OHIP

Confidentiality Agreement (Found within the Course Outline) Email a signed copy

Required

The nurse must attend two days of Online Clinical training with their preceptor. The online training should closely coincide with their onsite clinical training. *

I understand that my preceptor and I need to attend online clinical training with Soft Soles.

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