Preceptor Application Form
All fields are required.
Your Personal Information
Full Legal Name
Profession
Medical
Nursing
Pharmacy
Social
Malpractice Insurance Number
Please request proof of insurance from your provider within 4 weeks and mail it to:
SHINE CLINIC
ATTN: Odell Pui
c/o Boyle McCauley Health Clinic
10628 - 96 Street
Edmonton, AB T5H 2J2
Answer a Few Questions
Why do you want to be a preceptor at the SHINE Clinic?
What experiences and skills, particularly in working with the under-served inner-city youth, would you bring to the SHINE clinic?
What are your expectations of your experience as a SHINE preceptor?
Your Account Information
Username
Email Address
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