Clinical Affiliation Request Form | College of Nursing | Union University, a Christian College in Tennessee

Clinical Affiliation Request

STOP: Students do not complete this form without first getting approval from Your Clinical Advisor

Use this form to provide the information for the Union School of Nursing representative to request a Clinical Affiliation Agreement between Union University and the hospital or clinic which you would like to utilize for clinical rotations.

Please be aware that requests may take the hospital or clinic 2 to 3 months to process.

Please submit your requests at least 90 days in advance (but not more than 6 months in advance).

Contact Information

Your Name (person filling out this form)*

Your Union Email*

Graduate Student's Name (if applicable)

Type of Student*

Undergraduate - Jackson/Germantown
Undergraduate - Hendersonville
Graduate - MSN: Administration or Education
Graduate - MSN: Nurse Practitioner
Graduate - DNP: Executive Leadership
Graduate - DNP: Nurse Practitioner

STUDENTS ONLY: What is your Clinical Advisor's first and last name.

your advisor was assigned in October of your first semester

Clinical Information

Name of the Facility for the Clinical*

Facility = the clinical site, school, or agency that you are seeking to have Union University contract with (For graduate students requesting a Baptist facility, see note below)

Physical Address of the Facility*

please include the street address, city, state, and zip code

Contact Person at the Facility responsible for Clinical Affiliation contracts*

Contact Person's Email at the Facility*

Contact Person's Phone at the Facility*

Name of the Person at this Facility Who has Agreed to be Your Preceptor

this is a required item for all graduate students

Expected start date for the clinical rotation at this Facility*

Please feel free to add any pertinent information.

Note regarding Baptist Hospital Systems for Graduate Students Only

If the facility listed above is a "Baptist Hospital Systems" facility, do we have an existing contract on the CON Teams?

Yes No

If no, we must still proceed with obtaining an individual contract between you and the facility.
If yes, we must obtain two contracts, one between Baptist and Union, as well as an individual contract between the student and facility. [These contracts are in addition to the required preceptor contract.]

The facility, individual, and preceptor contracts for Baptist facilities all require the Vice President's signature as well as going through the legal department of their facility. Please allow 2 to 3 months for processing.

After you have completed this Union-required application, please go to https://www.baptistonline.org/gradnurse-application (click now to open in a new window) to initiate the Baptist student MOU application as well.

Upload a File

Contract Form

This form is now complete and you may submit. However, if you have already obtained a contract form from the agency, please attach it here. (Please make sure the file ends with .pdf.)

Please type what you see above
(it is case sensitive)
*