Affiliation information

This form needs to be:

fully completed and signed by the student/trainee

Upload the form on Blackboard two weeks before the affiliation starts

If the student doesnt meet these requirements, the affiliation will be invalid
and no study points will be granted to this affiliation (neither afterwards!!)

Personal information trainee

Surname:

First name:

Student number:

Date of birth:

Nationality:

Address during the affiliation:

Telephone address:

Telephone mobile:

E-mail student/trainee:

Telephone
parents/guardians:

E-mail parents/guardians:

Information affiliation placement organization

Name affiliation placement:

Affiliation address:
1
Telephone:
Fax:
E-mail:
Representative affiliation:
Start of the affiliation date
End of the affiliation date
Information Dutch educational institution
Name educational institution: Saxion Universities of Applied Sciences
School of Health
Postal address: P.O. Box 70.000
7500 KB Enschede
The Netherlands
Visitors address: M.H. Tromplaan 28
Enschede
Telephone: +31 (0)88 0193525
E-mail affiliation secretary: j.s.basut@saxion.nl
E-mail affiliation coordinator: r.timmers@saxion.nl
c.j.m.rensen@saxion.nl
Name education supervisor:
Telephone education
supervisor:
E-mail education supervisor:

Student/trainee: Place: Date: Signature: