Educational Affiliation Request Form

Educational Affiliation Request Form

Thank you for your interest in Guthrie as an educational affiliate. In order for us to evaluate your request, please provide the requested information. It is recommended that you review the informational items/questions prior to completing so that you are able to submit once it is completed. Many items are required (*) and the form will not submit without that required data. Please remember to mark the "CC" me a copy box at the end of the form so that you have a record of the request.

Date of Request:*

School/University/Affiliate Name*

Type of Request:*

Is this a NEW or Renewal request?

Select

Type of Student:*

Please identify the type of student served by this requested agreement.

Is this request on behalf of a Current Guthrie Employee?*

Please indicate if this request for affiliation is related to a current Guthrie employee using the drop down menu.

Select

Provide Guthrie Employee Name if relevant to this request.

If the request is on behalf of a current Guthrie Employee - please provide the name of the employee.

Target State Date:*

What is the target state date for student placements if approved? Please be advised that affiliation agreements take between 90-120 days to complete.

Guthrie Entity*

Please select the Guthrie entities where you would like students to rotate.

Select

Name of Affiliate Contact:*

Please identify the affiliate contact who will assist in development of this agreement if approved to proceed.

Title of Affiliate Contact:*

Affiliate Address:*

Affiliate Contract Phone Number:*

Phone

Affiliate Contact Email Address:*

PHI Collected?*

Select

What percentage of your students are from north central PA?*

Prior to sending students do you identify individuals who are potentially interested in a career at Guthrie?*

Where do students graduating from your program generally find jobs?*

If known, when was the last student that graduated from your program hired at Guthrie? What was their name?

File Upload

Please upload any supporting documents that might better help us evaluate your affiliation request. Ideally, a current Certificate of Insurance would also be uploaded at this time.

Drag and drop files here or

Send me a copy of my responses

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