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Non-Clinical Student Application

Please fill out the form below to apply for non-clinical student placement at Southlake.

Non Clinical Student Placement 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 (please choose one):
- Biomedical Technician
- Event and Venue Management
- Medical Office Assistant
- Public Relations
- Electrical Engineering Technician
- Health Information
- Operations Management
- Sterile Supply
- Other
Other program of study:
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
Name of educational institution:*
Number of hours required for placement:*
Name of faculty contact person:*
Faculty contact email address:
Questions or additional brief information you would like to provide:
Application category:*
- Allied health student placement
- NP/Masters of Nursing/PhD
- Non-clinical student placement
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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