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.

All Clinical Experience Agreements have mandated insurance requirements that must be met by a potential clinical agency.

Mortuary Science or Vehicular Field Training Agreements: It is highly recommended that faculty 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.
Health Care Program Clinical Experience Agreements: All facilities must have required insurance coverage, but it is not necessary for the District to obtain an insurance certificate as a prerequisite to processing an agreement. Please contact Jane Werth at 480-731-8260 or Angela Ford at 480-731-8935 for more information on insurance requirements for those agencies.

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

Requestor:	Name*:
	E-mail*:
	College*:	CGCC DSSC EMCC GCC GWCC MCC MSC PVCC PC RSC SMCC SCC SWSC
	Phone*:
	Program Type:
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 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
Comments:

Questions or comments?
Contact Margaret E. 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 11/06/2009