Placement Provider Application Form | Lambton College

Placements

Placement Provider Application Form

Are you interested in becoming a Field & Clinical Placement Provider for Lambton College students?

Please complete the below form and we will contact you to schedule a time to discuss the Field & Clinical Placement Provider requirements in further detail.

* indicates a required field

* First Name:

* Last Name:

* Facility Name:

* Address Line 1 (street number and name):

Address Line 2:

* City:

* Province/State:

* Country:

* Postal/Zip Code:

* Phone Number:

Ext:

Phone Number (Other):

Ext:

* E-mail Address:

* Confirm e-mail address:

Insurance:

  WSIB

  Private

* Number of students you are willing to take at a time:

Confidentiality Agreement

I consent to The Lambton College Field & Clinical Placement Liaison sending me electronic messages. I understand that I may withdraw my consent and unsubscribe at any time at the bottom of any electronic communication that is sent to me.

  Yes, I consent to receiving electronic messages.

  No, I do not consent to receiving electronic messages.