The University of Massachusetts Amherst
Affiliation Agreement Request Form

Please complete the form below ONLY if the facility has told you that they need an affiliation agreement

Do not confuse an Affiliation Agreement with the Student-Preceptor Form that you fill out for each preceptor. 

  • An affiliation agreement is a legal contract between UMass Amherst and the corporation that owns the site of your practicum. UMass does not need an affiliation agreement for you to do your practicum. For the many sites that do not need an agreement, you can go there without the lengthy months-long process it takes to complete an agreement. But some sites do insist on an agreement and will not let you work there without one. 
  • It is your responsibility to find out if an agreement is needed. If you don’t know who to ask, start with the HR department or the administration. Your preceptor might not know.
  • We will need the contact information for the person we will work with to get the agreement done. If you list the wrong person who does not work with agreements, that can create delays.
  • Allow enough time to execute an agreement. It can take 2 to 6 months to complete. Six months is rare but it does happen. And sometimes, even rarer, UMass and the site cannot reconcile our disagreements and the affiliation agreement is not completed. I will keep you posted on progress of agreement. Have a backup site available in case this happens.
  • If your site has any questions, we are happy to answer any they might have. Contact AJ Juno, ajuno@umass.edu

 

First and last name
Please include the full name of the facility (no abbreviations)
Please provide the first and last name of the person who works on agreements