Clinical Coordinator Status Appointment Application In accordance with the process for Status Appointment applications, please fill in and submit the information below. The Office for Clinical Education will review your application and forward you confirmation by mail. If you have any questions, please e-mail clinicaleducation@michener.ca or call (416) 596 3101 ext. 3328Part I - Clinical Coordinator InformationName * Required Mr.Mrs.Ms.Dr.Prof. Prefix First Last Clinical Site * Required Address * Required Street Address Address Line 2 City Province / State / Region Postal Code / ZIP AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position * Required Department Email * Required Phone * RequiredFaxProfessional Certification(s) * Required Michener Program * RequiredAnesthesia AssistantCardiovascular PerfusionChiropodyDiagnostic CytologyGenetics TechnologyImaging InformaticsMagnetic Resonance ImagingMedical Laboratory SciencesNuclear Medicine & Molecular Imaging TechnologyRadiation TherapyRadiological TechnologyRespiratory TherapyUltrasoundPart II - Registrar InformationThe following information will only be used by the Registrar’s Office for registration purposes and consolidation of duplicate records.Is this a renewal application? * Required Yes No Existing Michener registration number (if known)Birth Month * RequiredJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberBirth Day * Required12345678910111213141516171819202122232425262728293031Are you a Michener alumni? * Required Yes No Part III - AcknowledgementI recognize and agree to fulfill the responsibilities required by the status-only appointment as Clinical Coordinator: Administration and coordination of the student’s clinical education Liaison with Michener for the placement of clinical students Direct communication link between the clinical site at the department level and the Clinical Education Office and program Clinical Liaison Officer at Michener Overall supervision of the education and evaluation of clinical student(s) Direct accountability for the clinical student’s overall attainment of all clinical competencies Annual identification of staff members assigned to be clinical educators * Required I agree. Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Please check this box only if you do not grant permission to have your name and/or photograph published in future Michener publications and on the Michener website. I do not grant permission Please also provide your Manager/Supervisor’s information below to validate support for this application. Manager/Supervisor Name * Required First Last Manager/Supervisor Email * Required
