Nurse Apprentice Program – Updated Participation Agreement

Nurse Apprentice Program ARPA Grant – Participation Agreement – Updated 01.28.2025 (Existing)

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Date

Facility Name(Required)

Legal name of facility for contractual purposes (please include DBA as appropriate)

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

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)

Nevada Nurse Apprentice Program

Nurse Apprentice Program ARPA Grant – Participation Agreement – Updated 01.28.2025 (Existing)