Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

The Methodist Student Nurse Practitioner Program

Thank you for your interest in The Methodist Student Nurse Practitioner program. A Nurse Practitioner will contact you within five to 10 business days regarding your eligibility and the availability of our program. If you are not contacted within that timeframe or if you have a question regarding a previously submitted application please contact Christy Chukwu, MHA at cchukwu@tmhs.org or 713-441-4565.

* Indicates required information
First Name: * 
Middle Initial * 
Last Name: * 
Date of Birth: * 
Student ID Number: * 
Texas RN License Number: * 
Mailing Address: * 
Address 2: 
City: * 
State: * 
Zip Code: * 
Phone: * 
E-Mail Address: * 
School: * 
Semester/Quarter: * 
Expected Date of Graduation:
(Example: Fall 2011) * 
Course Name/Number: * 
Type of Program: * 

If Other, please specify:

Program Director: 
Program Director Phone: 
Program Director Fax: 
Program Director E-mail: 
Course Faculty: 
Course Faculty Phone: 
Course Faculty E-mail: 
Type of Unit/Area Requested: 
Number of Clinical Hours: 
First Clinical Day: 
Last Clinical Day: 
Name of Preceptor Request/Area of Experience (if applicable): 
Authentication * 

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