For Post RN Specialty Certificate Placements
Placement Request Form
For Post RN Specialty Certificate Placements
Type your application & include your name and academic institution in the file name.
Email completed request form to your Academic Placement Coordinator.
Note that this form will be shared with SickKids educators and potential preceptor(s) as part of the placement request process.
Applicant Personal Profile
Salutation: Choose an item.Last Name:Click here to enter text.
Telephone:Click here to enter text. / First Name:Click here to enter text.
Email:Click here to enter text.
Placement Coordinator / Course Instructor
Name:Click here to enter text.
Email:Click here to enter text.
Telephone:Click here to enter text. / Name:Click here to enter text.
Email: Click here to enter text.
Telephone:Click here to enter text.
Applicant’s Academic Profile / Academic Program
School Name:Click here to enter text.
School Address:
Click here to enter text. / NICU Certificate:
CCU Certificate:
OR Certificate:
Continence Certificate:
Ostomy Certificate:
Other Certificate: Click here to enter text.
RN Refresher:
Duration of Placement- please specify EXACT start and end date
Start Date: Click here to enter a date. / End Date: Click here to enter a date.Requested Clinical Area-please indicate your choice from the drop down menu
1.Choose an item.
Additional Applicant Informationplease check as many boxes as apply
Prior Paediatric Experience:
Employment School Rotation
Where/When: Click here to enter text.
Prior/Current Employment at SickKids:
RN Other
When: Click here to enter text.
Current Certification:
RN Other:Click here to enter text.
Identify your learning objectives for the placement
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Identify your previous work history related to your request (point form)
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This section needs to be completed by the academic placement coordinatorI have reviewed thisapplication and I agree with the choices for placement and the information supplied. The student demonstrates the requisite knowledge, skills, and judgement for the requested placement areas. The student has strong academic and clinical performance (a minimum of a B average).
If applicable, please indicate the placement days per week:M T W T FS S
Total Hours Required for Clinical Placement:Click here to enter text.
Name of Placement Coordinator:Click here to enter text.
Please email completed form to
VG-2017-10