Clinical Educator 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 Educator 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
Number of years teaching * 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 Educator:
- Excellence in clinical instruction
- Evaluation by students
- Adherence to clinical course outlines
- Commitment to professional development
- Direct contribution to the clinical student’s attainment of clinical competencies, as identified by the Clinical Coordinator
* Required
- I agree.
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
Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Please also provide the Clinical Coordinator's information below to validate support for this application.
Clinical Coordinator's Name * Required
First Last
Clinical Coordinator's Email * Required

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Part I - Clinical Educator Information

Part II - Registrar Information

Part III - Acknowledgement