MOU_01.28.2025

Nurse Apprentice Program ARPA Grant – Participation Agreement – Updated 01.28.2025

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Step 1 of 2

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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

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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 – Updated 01.28.2025