Nurse Apprentice Program ARPA Grant – Participation Agreement

Please review the agreement HERE before you signup.

Nurse Apprentice Program ARPA Grant – Participation Agreement

Please complete this form and we will generate an e-signature document. An email will be sent to you and your staff for your electronic signature. Please check your inbox or junk/spam folder.

Step 1 of 2

Hidden

Date

Facility Name(Required)

Legal name of facility for contractual purposes

Facility Physical Address(Required)

Street Address City State ZIP Code

Is the mailing address different from the physical address?

Yes

Mailing Address

(if different from above)

Street Address City State ZIP Code

Eligible Facility Type(Required)

Critical Access Hospital

Non-profit Community Hospital

Skilled Nursing Facility (SNF)

State Hospital

Long Term Acute Care Hospital (LTAC)

Other

Hidden

Facility Name(Required)

Authorized Signer(Required)

First

Last

Authorized Signer Title(Required)

Authorized Signer Email(Required)

Director of Nursing Name(Required)

First

Last

Director of Nursing Email(Required)

Facility Nurse Apprentice Policy(Required)

To ensure you are eligible for this program please upload your Nurse Apprentice Policy.

Drop files here or

Max. file size: 20 MB.

Fiscal/Finance Staff Member(Required)

First

Last

Fiscal/Finance Contact Email(Required)

Fiscal/Finance Contact Phone(Required)

Nevada Nurse Apprentice Program

Nurse Apprentice Program ARPA Grant – Participation Agreement