Lawrence S. Bloomberg Faculty of Nursing

Dear incoming BScN students 2011:

Please take a few minutes to complete this online form aimed at assisting the Faculty in determining clinical placements.

You are required to complete this online form by September 1, 2011.

Thank you,
Student Services
Lawrence S. Bloomberg Faculty of Nursing

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LAST NAME: FIRST NAME: Your surname and first name indicated in this form must be identical to your official U of T record in ROSI. UTOR E-MAIL ADDRESS:  Enter a valid email address. Example: name@company.com HOME PHONE NUMBER:  Enter a valid phone number. Example: 123-456-7890 CELL PHONE NUMBER:  Enter a valid phone number. Example: 123-456-7890 ADDRESS DURING SCHOOL YEAR AS INDICATED IN ROSI MAJOR INTERSECTIONS OF ABOVE ADDRESS: METHOD(S) OF COMMUTING: TTC GO Train Car Bicycle CLOSEST SUBWAY/GO TRAIN STOP: IN CASE OF EMERGENCY NAME AND NUMBER OF PERSON TO CONTACT: ANY INFORMATION THAT WOULD BE HELPFUL FOR FACULTY TO KNOW IN DETERMINING ASSIGNMENT OF CLINICAL PLACEMENTS? (eg, day care, babysitting arrangements/challenges, particular interests or skills that might be relevant for some placements, etc):