Student Placement Application Form | Reconnect Community Health Services

Student Placement Application Form

Name:

Address:

City:

Province:

Postal Code:

Phone:

Email:

Status in Canada:

Educational Institution:

Program of Study:

Degree/Diploma/Certificate to be granted:

Year of Study:

Expected Date of Completion:

Professional Body Affiliation (if any):

Practicum Start Date:

Practicum End Date:

Number of Hours Required:

Student Preceptor Perquisites set out by your Educational Institution:

Academic Contact Name:

Academic Contact Phone:

Academic Contact Email:

Please describe any relevant experience you have obtained thus far:

Please outline your practicum objectives/goals and interests:

Please indicate the top three programs that are of interest to you in priority order (i.e. first choice, second choice, third choice):

Please attach your cover letter in Microsoft Word of PDF format

Please upload Resume in Microsoft Word or PDF format

Donate to Reconnect

We depend on the generosity of donors to make needed purchases and sustain programs and activities not financed by our major funders.

Charitable Organization No. 107352528RR0001

Contact

1709 Bloor St W

Toronto, ON M6P 4E5

Phone: 416-248-2050

Email: contact@reconnect.on.ca

Fax: 416-248-6557

Funders