Undergraduate Program

Application for Clinical Nurse Internship NURS 305 (1 Credit)

Jan Term 2018

Date of Submission: ____________________________________________________________________ Student’s Name: (First) (Middle) (Last)

Mailing Address: (Street)

(City) (State) (Zip Code)

Cell Phone #: Courses Enrolled in during Fall 2017: _______________________________________________________ _____________________________________________________________________________________ Work Experience: Career Plans: __________________________________________________________________________ _____________________________________________________________________________________ Do you plan to accept a nursing position in Birmingham upon graduation? ________________________ List the two faculty members who have written letters of recommendation (attach letters): __________________________________________________________________________________________________________________________________________________________________________ I affirm that all the information provided is true and understand that any false information will forfeit my qualification to be considered for the clinical nursing internship. Print Name Signature Date

Office Use Only Overall GPA: Samford GPA: __________ Nursing GPA: _________ Recommendation # 1: Favorable With Reservations Unfavorable __________ Recommendation # 2: Favorable With Reservations Unfavorable __________ Comments: ____________________________________________________________________________________ Decision: Approve: Do Not Approve: Rationale: Clinical Agency Assigned: _________________________________________________________________________

Undergraduate Associate Dean’s Signature: __________________________________________________________