New Visiting Student Application

Visiting Student Application

To be completed by an institutional representative

This form must be completed by a representative from the Home Institution in which the student is enrolled. Please note that all information will be subject to audit and verification. Please visit the Allied Health Visiting Student Information Page for more information.

Student Information

First Name

Middle Name

Last Name

Cell Phone

Street

City

State/Province

Zip/Postcode

Pref. Language

Emergency Contact Name

Emergency Contact Phone

Home Institution

NOTE: The "Home Institution" refers to the institutuion in which the student is currently enrolled.

Home Institution/School

Anticipated Graduation Date

Home Institution Contact Name

Home Institution Contact Email

Additional Comments

Vanderbilt Contact Information

Please provide the information regarding the clinical department students will visit as well as the name(s) of the VUMC preceptors or point of contact for the student. If the student has more than one rotation scheduled, please provide the additional rotation dates. Any additional information can be provided in the comment box.

Clinical Department

VUMC Contact Name

Clinical Rotation Start Date

Clinical Rotation End Date

Will the student have more than one rotation?

Yes No Not Selected

Clinical Rotation 2 Start Date

Clinical Rotation 2 End Date

Comment

Attestation Statements & Signature

By checking the Attestation Statements and signing below, you are confirming that the home institution maintains the documentation required and will produce proof of documenation in the event of an audit.

I attest that the institution has current health insurance on file for the student

Yes No Not Selected

I attest that the institution has a current background check on file for the student

Yes No Not Selected

I attest that the institution has a Liability Insurance Policy on file

Yes No Not Selected

I attest that the institution has an Affiliation Agreement with VUMC

Yes No Not Selected

I attest that the institution has a current immunization record on file for the student

Yes No Not Selected

Institutional Representative Signature

Date of Submission