Student Application | Broadlawns Medical Center

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?

Yes

If yes, please describe:

In case of emergency we should contact:

Name

Relationship

Phone

Alternate Contact:

Name

Relationship

Phone

Background Information

Do you have a record of child or dependent adult abuse?

Yes

If yes, please describe:

Have you ever been convicted of a crime in Iowa or in another state or country?

Yes

If yes, please describe:

Signature

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.

Name:

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.

Name:

Date:

Agreement

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.
I understand my responsibility to be on time, attentive, courteous, and protective of patient confidentiality.
I understand that in the performance of my duties as a student, I must hold in strictest confidence any observations I may make or hear regarding patients, patient families, clients, staff, or volunteers.
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.).

Name:

Date: