MCCCD Legal Services Department - Clinical Experience Agreement Request Form

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Clinical Agreement Request Form

Complete and submit the following form and an agreement will be sent to the facility within two business days. To check the status of the agreement, please search our Clinical Database. In order to expedite processing, please provide all of the requested information. Required fields are marked with an asterisk (*). Any missing information may delay processing.

It is highly recommended that you contact the facility and request a Certificate of General Liability Insurance that meets the District's insurance requirements upon completion of this request form. We are unable to process any agreements without proper insurance coverage.

An e-mail confirmation will be sent to you once your request has been processed. If you have any questions, please contact Chanda Fraulino at 480-731-8881.

Requestor:	Name*:
	E-mail*:
	College*:	CGCC DSSC EMCC GCC GWCC MCC MSC PVCC PC RSC SMCC SCC
	Phone*:
Agency / Facility:	Name*:
	Contact Person*:
	Address1*:
	Address2:
	City: State: Zip*:
	Phone*: Fax:
	E-mail: (Please provide e-mail address if you would like the agreement sent via e-mail to the agency.)
Legal Designation:	corporation^ non-profit corporation^ ^---->**State of Incorporation: professional corporation limited liability company partnership sole proprietorship other
*Type of Agreement:**	Clinical Experience Agreement ("CEA") CEA for Dental Program (Waiver Request Only) CEA for Medical Assisting (Waiver Request Only) CEA for Mortuary Science CEA for Student Employed by Agency This agreement is for a single student in a specific program that desires to do their clinical experience at an agency in which they are currently employed. The following information is required: Student Name: Healthcare Program : Start Date : End Date : Joint Appointment Agreement Vehicular Field Training Agreement Waiver Request - For Dental and Medical Assisting Programs Only If an Agency's insurance carrier/broker charges a fee to add MCCCD as an additional insured to their general liability insurance policy, then you may request a waiver agreement. The waiver request only applies to the additional insured requirement. Agency must still furnish an insurance certificate as required by the agreement that meets MCCCD's insurance requirements. Please note that approval from your college President for the waiver must be on file in Legal to request these agreements.
Comments:

Questions or comments?
Contact Margaret McConnell @ 480.731.8888

Office of General Counsel
2411 West 14th Street
Tempe, AZ 85281-6942
480.731.8877 / 480.731.8890 fax

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Page Updated 05/20/08