CentraCare Health - St. Cloud Hospital – Nurse Residency Program
Supplemental Application
Full Name:
Phone Number:
E-mail Address:
Nursing School:
Nursing Degree:
____ ADN
____ BSN / BAN
____ MSN
Nursing GPA:
Date of Graduation:
Nurse Internship Experience:
___ Yes
___ No
Internship Location:
Internship Unit/Department:
Final Nursing Clinical Location:
(capstone, immersion, etc.)
Final Clinical Dates:
Final Clinical # of Hours:
Final Clinical Unit/Department:
Current CentraCare Health
Employee:
Current Position:
Current Unit/Department:
Previous CentraCare Health
Employee:
Previous Position:
Previous Unit/Department:
___ Yes
___ No
___ Yes
___ No
Date of Hire:
Dates of Employment:
Previous Healthcare Experience:
In 250 words or less, explain what “Professional Nursing” means to you.
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Briefly describe the short and long term goals for your nursing career.
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Placement Interest Inventory:
CentraCare Health is dedicated to providing support and resources to graduate nurses as they
transition from academia to professional nursing practice. With the classroom and clinical orientation
provided by the nurse residency program, candidates have been successfully placed in a variety of
inpatient and outpatient settings. Please rank your top 4 areas of interest in order and select your
level of interest in other units/departments. Mark your choices with an “X.”
Rank
(1-4)
Unit/Department
Strong
Interest
Interest
No
Interest
Behavioral /Mental Health
Bone & Joint
Cardiac Care Unit (Cardiac ICU)
Center for Surgical Care
Dialysis
Emergency Trauma
Family Birthing Center
Home Care / Hospice
Intensive Care Unit
Medical
Medical Progressive Care
Neonatal Intensive Care
Neuroscience / Spine
Oncology / Cancer Program
Operating Room/Surgery/PACU
Outpatient Services
Pediatrics
Patient Care Support – Float Pool
Rehabilitation
Surgical Care
Telemetry
Other:
I have requested letters of reference from the following nursing instructors:
Name: _________________________________ Title: _______________________________
Name: _________________________________ Title: _______________________________
I have requested a letter of reference from the following previous employer:
Name: _________________________________ Title: _______________________________
I have applied to the Graduate Nurse Residency Program at St. Cloud Hospital.
I request and authorize you to release the information requested from the references listed above.
Applicant Name
(typed version equals signature)
_____________________________ Date:_______________
Complete this form and email it to: LatourS@centracare.com