Student Placement Coordination Support Form 26-27

For late registration of coordination funds:

Please fill out this form to receive student placement coordination funds ($30,000) if your LTC home has not already registered for the funds on the enrollment form. If you are unsure if your LTC home has already registered, please confirm with your REL.

Select your LTC home from the list below. Please ensure you select the correct home name and only select a LTC home once.

LTC Home(Required)

If you are unable to select your LTC Home from the list, please contact us before continuing.

Home Name

Email Address(Required)

Contact Name(Required)

First Last

Please describe the impact Coordination Support Funds have had on your LTC home and student clinical placements during your participation in PREP LTC over the years. If this is your first year registering for Coordination Support Funds, what impacts do you anticipate?(Required)

Student Placement Coordination Funding Acknowledgement(Required)

I acknowledge that my home (name selected above) will use PREP LTC student placement coordination funding to start up or expand student placement coordination support.

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