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Allied Health or Continuing Education Nursing Student Application

Please fill out the form below to apply for an allied health or continuing education nursing student placement.

Allied Health or Continuing Education Nursing Student Application

First name of student:*
Middle name of student (enter 'N/A' if you do not have one):*
Last name of student:*
Email address of student:*
Please re-enter your email address:*
Phone number of student:*
Program of study:
- Cardiovascular Technology
- Child and Youth Worker
- Communicative Disorders Assistant
- Diagnostic Cardiac Sonography
- Kinesiology
- Medical Laboratory Assistant/Technician
- Medical Laboratory Technology
- Medical Radiation Technologist (MR) – Magnetic Resonance
- Medical Radiation Technologist (N) – Nuclear Medicine
- Medical Radiation Technologist (T) – Radiation Therapy
- Medical Radiation Technologist (R) – Radiography
- Nursing Continuing Ed – Critical Care
- Nursing Continuing Ed – Surgical
- Nursing Continuing Ed – Wound
- Nutrition/Dietitics
- Occupational Therapy
- Occupational Therapy Assistant
- Pharmacy
- Pharmacy Technician
- Physiotherapy
- Physiotherapy Assistant
- PT and OT Assistant (combined)
- Respiratory Therapy
- Social Work (MSW)
- Sonography
- Speech-Language Pathology
- Spiritual Care
- Therapeutic Recreation
Other program of study (not listed above):
Current program level:
- Diploma
- Bachelor Degree
- Masters Degree
- Certificate
Placement preference (e.g. specialty area):
Placement start date:
MM slash DD slash YYYY
Placement end date:
MM slash DD slash YYYY
Number of hours required for placement:*
Name of educational institution:*
Name of faculty contact person:*
Faculty contact email address:
Questions or additional brief information you would like to provide:
Application category (for office use):
- Allied Health Student Placement
- Non-Clinical Student Placement
- NP/Masters of Nursing/PhD
- Nursing Continuing Education
Please indicate if you or your school have already contacted a clinical/field instructor at Southlake (excluding your Professional Practice contact person).*
- Yes
- No
If yes, please enter the name of the Southlake instructor:

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T 905-895-4521
TTY 905-952-3062

596 Davis Drive, Newmarket, Ontario L3Y 2P9

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