Preceptor Form
This form is to be completed and signed by the preceptor.
Name of Preceptor 

___________________________________________________________________________
Position Held by Preceptor 

___________________________________________________________________________
Name of Facility 

___________________________________________________________________________
Address of Facility 

___________________________________________________________________________
___________________________________________________________________________
City and State 

___________________________________________________________________________
Preceptor’s Email Address 

___________________________________________________________________________
Preceptor’s Contact Number 

___________________________________________________________________________

Thank you for considering to precept this student towards becoming a registered dietitian. If you have any questions, please do not hesitate to reach out to:
Dona Greenwood, PhD, RDN, LDN, FAND, Program Director 
mdgreenwood@keiseruniversity.edu

This form needs to be submitted by the student with the DICAS paperwork in the supplement column.