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Student Application




School and Hospital Area
Application date:
Program:
Class start date:

Student Information

First name
MI
Last name
Address
City
  
County
  
State
  
Zip
Preferred email address
  
Primary phone
School name
  
City
  
Anticipated grad. date

Emergency Information

Do you have medical limitations or conditions the hospital should be aware of in the event that you ever have a medical emergency while there?
If YES, please describe.
In case of an emergency we should contact:
Name
Relationship
Phone
Alternate contact
Relationship
Phone

Background Information

Do you have a record of child or dependent adult abuse?   
Have you ever been convicted of a crime in Iowa or in another state or country?   
If YES to either of the above, please explain:

Educational Level Currently Enrolled (select one)





























Health Profession Discipline






























Agreement

  1. I agree to the following requirements, with the understanding they may be required for my internship/clinical rotation/job shadow experience at Broadlawns Medical Center*:
    • Turberculosis (TB) skin test within last 4 years.
    • MMR tier or proof of immunization - 2 doses.
    • Physical exam within the last 4 years. Not required for job shadowing.
    • Criminal background check.
    • Wear school or student identification badge at all times during internship/clinical rotation/job shadow experience.

    *If you do not have one of these requirements, please contact Kari Ford at (515)282-2278 or Dianna Peterson at (515)282-2483.

  2. I understand my responsibility to be on time, attentive, courteous, and protective of patient confidentiality.

  3. I understand that in the performance of my dutiews as a student, I must hold in strictest confidence any observations I may make or hear regarding patients, patient families, clients, staff, or volunteers.

  4. I understand that intentional or involuntary violation of confidentiality may result in disciplinary action, including termination of my own internship/clinical rotation/job shadow experience and/or possible legal action by others (i.e. patients, patient families, clients, staff, etc.).

Signature
Date

Release of Liability

I hereby agree that while I am participating in any education experience, Broadlawns Medical Center will not be held responsible for any injury or accident that might occur. Any medical expenses incurred as a result of such injury or accident will be my responsibility.
Signature
Date

Release of Information

I give my education facility permission to release my medical history as needed by Broadlawns Medical Center for auditing and regulatory purposes.
Signature
Date

FOR JOB SHADOW APPLICANTS ONLY

Time Availability and Preference

Monday Tuesday Wednesday Thursday Friday
Morning Hours (e.g. 8-12)
Afternoon Hours (e.g. 12-5)

Areas of Interest

1801 Hickman Road, Des Moines, IA 50314-1597 | Phone 515-282-2200 | Fax 515-282-3589
© Copyright 2014 Broadlawns Medical Center | Anti-Retaliation Policy