Nursing Student Mentoring Request

Contact: Michele Spagnola, Administrative Assistant
Office: Jacobsen Hall, Room 417
Phone: 315 464-5463
Email: spagnolm@upstate.edu

If you are a nursing student and would like to work with a Nurse Clinical Educator as a mentoring experience, please fill out this form.

* = required field

*First Name:
*Last Name:
*Email Address:
SUNY Upstate Employees only:
Employee ID#:
Department:
If non-SUNY Upstate employee, enter in employer:
*Are you a student at SUNY Upstate College of Nursing?	Yes No
If no, please specify college name:
Dates you are requesting a mentor:
Number of hours you are requesting a mentor:
Name of Clinical Educator being requested (if applicable):
*Please list course clinical objectives/purpose: