Health Sciences Rural Practicum Bursary Application

The personal information that you provide on this form is being collected under the authority of the Freedom of Information and Protection of Privacy Act of Alberta, section 33(c). It will be protected in compliance with the provisions of the Freedom of Information and Protection of Privacy Act of Alberta and will be retained in accordance with the Information Management policy and guidelines. This information will be used by the Student Connect Centre for the purpose of selecting the recipient(s) of awards and scholarships. If you have questions regarding this form, please contact the Student Connect Centre, room 1102, Red Deer Polytechnic, Box 5005, 100 College Blvd, Red Deer, Alberta, T4N 5H5, 403.342.3254.

Personal Information

First Name

Last Name

Student ID Number

Email Address

Phone Number

Please input your 10-digit phone number with area code.

Practicum Information

Program of Study

Bachelor of Science in Nursing

Practical Nurse

Occupational and Physical Therapist Assistant

Course

When does your practicum begin?

Who is your practicum instructor?

Please provide first and last name.

In which city/town is your practicum located?

Did you select or request this practicum location?

Yes

How many working practicum days are you scheduled to attend? days

Acknowledgement

I understand that bursary recipients are expected to attend a meet and greet with the bursary donors (to be scheduled at a later date).

Signature

This electronic signature is treated by RDC like a handwritten signature on a paper form.

Health Sciences Rural Practicum Bursary Application

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