2020-2021 Emerging Health Professionals Application
Lehigh Career & Technical Institute
Student Date of Birth
Parent Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Student's Grade for the upcoming school year
Student's School District
District in which student resides
Student Ethnicity: Choose one.
Prefer not to answer
Student Race: Choose one.
American Indian or Alaska Native
Black or African-American
Native Hawaiian/Other Pacific Islander
Two or more races
Prefer not to answer
Student Gender Identity:
Genderqueer, gender non-conforming, non-binary
Prefer not to say
Prefer to self-describe
Prefer to Self-Describe
I here by permit and authorize Lehigh Valley Health Network for a period of one year of the date of this application to perform any and all treatment including, but not limited to medical, dental and surgical, that may be necessary for my child. The following information is being requested in order to be able to react appropriately in the event of an emergency concerning the student observer. Please provide any information which might be relevant in the case of an emergency. This information will be shared with those staff involved in the student observation. **Please remember that if you/your child has been exposed to a communicable disease,including Chicken Pox, Measles, Mumps, Rubella, Herpes Zoster, Conjunctivitis,Tuberculosis and Hepatitis, do not allow them to attend any LVHN activities.
Family Physician Phone
Name of Medical Insurance Carrier
Medical Insurance Policy #
Medical Insurance Carrier Phone Number
List any medications.
List any allergies/health concerns.
Consent to Participate
I hereby request/grant permission for me/my child to participate in the Lehigh Valley Health Network/ Shadowing/Observation Program. I certify that I/my child is at least 16 years of age. I release Lehigh Valley Health Network and its subsidiaries, their respective employees, representatives and agents and any individual involved with the Shadowing/Observation Program from any and all liability associated with my child's participation in this program. I specifically authorize the following (click on the below boxes to authorize):
Conducting of interviews, tests, and questionnaires of or by student for program evaluation purposes.
Publicity activities, including interviews, photos, and videotaping.
Photography Consent Form
Please fill in your son/daughter's name and click the appropriate box.
I CONSENT to the taking and public use of any photographic, audio visual or other media recordings or representations of applicant by a person selected by Lehigh Valley Health Network. I hereby waive any right I may have to copyright,inspect, or approve the finished product that may be used here under, or the specific use or context to which it may be applied. I release Lehigh Valley Health Network, its components, employees, agents, and medical staff from any liability connected with the taking or use of these audio or visual recordings or representations.
I DO NOT consent to the taking and public use of any photographic, audio visual or other media recordings or representation of applicant by a person selected by Lehigh Valley Health Network.
Acknowledgement of Confidentiality
IMPORTANT: Please read all sections below. If you have any questions regarding this acknowledgment, please ask the person reviewing this with you to answer those questions before you sign this. I understand that as an employee of the Lehigh Valley Health Network (along with its components and subsidiaries), member of the medical staff, physician office employee or non-hospital patient care provider or support personnel (volunteer,intern, student, contractor, vendor, etc.), the performance of my job may require me to access or become aware of the following confidential information: patient health care and financial information, Employee personnel, compensation and health care information, physician performance and personnel information, business information relating to Lehigh Valley Health Network. I understand that approval to access and use this information in verbal, written,or electronic (stored in a computer) form is a privilege. I also understand that access to information is granted to me based on business or clinical “need to know” standards and the responsibilities of my job as an employee or non-hospital patient care provider or support personnel. I understand that I may not seek information that is not required to do my job. I also understand that I may share information only when necessary to do my job. I agree to store and dispose of information which I use in a way that ensures continued security and confidentiality. I understand that the methods I use to get information may only be used in the performance of my job. If I require special authorization to access computer-based information, I understand that my computer sign-on information may only be used by me. I also understand that I may not give my sign-on information to anyone, and that this information is the same as my written signature. I accept full responsibility for any use of my sign-on information. I declare that I have read and understand this acknowledgment. I have had an opportunity to ask questions and have them answered. I recognize that giving confidential information at any time during or after my employment or affiliation with Lehigh Valley Health Network may cause irreparable damage to Lehigh Valley Health Network, the patient or the health care provider. Accordingly, Lehigh Valley Health Network or the owner of such information may seek legal remedies against me, such as fines, criminal penalties, suspension or termination of employment.
Applicant’s signature verifying information on Application, Consent to Participate, Emergency Information, Photography Consent, Acknowledgement of Confidentiality, and verification of having read and will comply with the Etiquette policy.
Parent’s signature verifying information on Application, Consent to Participate, Emergency Information, Photography Consent, Acknowledgement of Confidentiality, and verification of having read the Etiquette policy (if applicant under 18)
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