CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW:
- I understand that Pinckneyville Community Hospital is not obligated to provide placement, nor am I obligated to accept a position if one is offered. Pinckneyville Community Hospital is committed to providing equal opportunities for all applicants, regardless of race, religion, gender, national origin, age, disability, marital status, or veteran status.
- I understand that all the services provided to Pinckneyville Community Hospital, its patients and their family members are of a confidential nature. I am obligated to refrain from discussing information I’ve heard, seen or otherwise learned about patients and other confidential information in the course of my activities at Pinckneyville Community Hospital with anyone outside the Hospital, including, but not limited to, my family, friends, media and social media. I will not pass on information to patients and visitors unless I’ve been instructed to do so by the Hospital employee(s) assigned to supervise my activities.
- I am obligated to govern myself by high ethical standards, details of which are outlined via Pinckneyville Community Hospital’s Code of Conduct and made available to me for my review on the Hospital’s website at www.pvillehosp.org.
- I affirm that I have received Compliance and HIPAA training from Pinckneyville Community Hospital. Signing this acknowledgement affirms that I have received training and will abide by expectations of confidentiality and ethical conduct as outlined in the Code of Conduct acknowledgement form. Failure to recognize the importance of confidentiality and ethical conduct is not only a breach of professional ethics, but can also involve legal proceedings.
- I understand that all of the student activities are performed without compensation and that applicant is not considered an employee of Pinckneyville Community Hospital.
- I understand to be considered for placement, I will comply with the immunization requirements outlined on the Student Orientation checklist/ applicable student policies.
- I affirm that the applicant has not been tried as an adult and has not been convicted of a forcible felony that would prohibit the applicant from working in a healthcare facility.
- Permission is further granted to Pinckneyville Community Hospital to provide necessary treatment for immediate first aid and other minor medical complaints as long as the service provided follows established Pinckneyville
Community Hospital policies. The release constitutes full release, without reservation, for the circumstances described herein.
- I hereby consent to and authorize the following uses and reproductions by Pinckneyville Community Hospital (PCH), including the Family Medical Center, Area Health Education Center (AHEC), or anyone authorized by Pinckneyville Community Hospital, for any purpose, including but not limited to news releases, marketing, advertising, videos, fundraising, the hospital website, social media sites, and media interviews. I (student, job shadower, or volunteer) consent to Pinckneyville Community Hospital's use of photographs of me, with or without my name, for such purposes, including but not limited to publicity, illustration, advertising, web content, bulletin board, newsletter, and recognition programs. I understand I will not be compensated for this use. All negatives, together with the prints, videos and testimonials shall constitute the property of PCH, solely and completely. I understand that I may revoke this authorization in writing at any time by contacting the Marketing Director or Administrator/CEO of PCH at 5383 State Route 154 Pinckneyville, IL 62274, except to the extent that action has been taken in reliance on this authorization. Anyone under 18 years of age, authorization must be given by parent or guardian by signing below.