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*
First Last
Clinical Site*
Address*
Street Address Address Line 2 City Province / State / Region Postal Code / ZIP Country
Position*
Department
Email*
Phone*
Fax
Professional Certification(s)*
Michener Program*
Number of years teaching*
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?*
- Yes
- No
Existing Michener registration number (if known)
Birth Month*
Birth Day*
Are you a Michener alumni?*
- 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
*
- 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*
MM slash DD slash YYYY
Please also provide the Clinical Coordinator's information below to validate support for this application.
Clinical Coordinator's Name*
First Last
Clinical Coordinator's Email*
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Part I - Clinical Educator Information

Part II - Registrar Information

Part III - Acknowledgement