This form is to be completed by students applying for academic placement at Hotel Dieu Grace Healthcare.

Completing this form does not guarantee a placement. We will contact you within 2-4 weeks to discuss further. Click on the CONTINUE button at the end of this form to submit your application.


* indicates fields required


Student Contact Information

Student name and email address



Emergency Contact Info


School Information

Schools in the drop down list below have an Affiliation Agreement with HDGH. If your school is not listed please do not submit a Student Application. Your school coordinator may contact us to begin the Affiliation Agreement application process. The Affiliation Agreement process may take anywhere from 2 - 6 months or more.



School Coordinator or Faculty Advisor Information


Placement Details


Placement Information - Assignment


Placement Information - Dates


Placement Information : Schedule

Preferred schedule and students availability during placement.



Additional Information

Include any additional information here: