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. 3328
Part I - Clinical Coordinator Information
Prefix
Name * Required
First Last
Clinical Site * Required
Address * Required
Street Address Address Line 2 City Province / State / Region Postal Code / ZIP Country
Position * Required
Department
Email * Required
Phone * Required
Fax
Professional Certification(s) * Required
Michener Program * Required
Part II - Registrar Information
The 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 * Required
Birth Day * Required
Are you a Michener alumni? * Required
- Yes
- No
Part III - Acknowledgement
I 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

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Part I - Clinical Coordinator Information

Part II - Registrar Information

Part III - Acknowledgement