SWORBHP Service Request for Training: Student Certification

THIS FORM IS TO BE COMPLETED BY A PARAMEDIC SERVICE.

If you are from a College and wish to request training, please complete the following form:
https://apps.lhsc.on.ca/?q=forms/sworbhp-college-request-training-student-certification

Please note, the Student/College will be required to submit payment prior to training via cheque to LHSC as per the following:
PCP: $350
ACP: $500

SERVICE CONTACT INFORMATION

Please provide your contact information for follow-up.

STUDENT PROFILE(S)

Student 1:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 2:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 3:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 4:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 5:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 6:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 7:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 8:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 9:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

Student 10:

First three characters of the college code (ie. FAN) / 'P' or 'A' to identify PCP or ACP student (ie. P) / Last 4 digits of the Student number (ie. 9876)
Note, this unique identifier is to be used on every ACR/ePCR for identification of the Student during Academic Certification.

Anticipated Preceptorship Date: Please indicate the preceptorship time frame

COMMENTS

Please feel free to provide additional comments/information:

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