Affiliation Agreement Request Form
IMPORTANT: Do NOT fill this out if you are in the Nurse Practitioner program. Please contact your advisor for your affiliation agreement form for MSN-NP students.
Student Name
*
First Name
Last Name
Student ID Number
*
Student Email
*
example@example.com
Select Your Program
*
Master of Science Nursing Education
Master of Science Nursing Case Management
Master of Science Nursing Informatics
Master of Science Nursing Infection Prevention and Control
Master of Science Nursing Management and Organizational Leadership
Master of Science Nursing Family Nurse Practitioner
Nursing Adult Gerontology Nurse Practitioner
Master of Science Nursing Psychiatric Mental Health Nurse Practitioner
Doctor of Nursing Practice
Facility Name
*
Is the facility you listed part of a larger organization or facility?
*
Yes
No
Name of "Umbrella" or Main Facility
*
Facility Contact Name
*
This should not be your Preceptor unless your Preceptor has signing authority to execute legal agreements at your facility.
Facility Contact Email
*
This should not be your Preceptor unless your Preceptor has signing authority to execute legal agreements at your facility.
Facility Location: City
Facility Location: State
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
American Samoa (AS)
Guam (GU)
Northern Mariana Islands (MP)
Puerto Rico (PR)
Virgin Islands (VI)
Canada
Does your facility fall under the umbrella of Kaiser Permanente?
Yes
No
COVID Exemptions Allowed
None
Medical Exemptions Allowed
Religious Exemptions Allowed
Medical and Religious Exceptions Allowed
Other
Additional Comments or Information
Submit
Back
Next
For Internal Use Only
To be filled out by the American Sentinel College Affiliation Agreement Team
Does the agreement cover multiple locations or facilities?
Yes
No
Is the agreement student specific?
Yes
No
If student specific; provide student name.
Type of Agreement
NP or Clinical (Covering Clinical and Didactic Hours)
Non-Clinical (Covering PE Hours only)
Status of Agreement
In Progress
Fully Executed
Expiration Date of Agreement
-
Month
-
Day
Year
If the agreement does not have an expiration date leave the date blank.
Should be Empty: