Other - RETURNING

New or Returning

Today's Date

First Name:*

Last Name:*

Email Address:*

Phone Number:*

School:*

Program / Type of Learner:*

e.g. Physician Assistant student, Resident, Nursing student etc.

Faculty Advisor Name & Title:*

Faculty Advisor Email:*

Faculty Advisor Phone:*

Emergency Contact Name:*

Emergency Contact Relationship:*

Emergency Contact Phone:*

Trinity Health Of New England site you're rotating at:*

Department you're rotating in:*

Trinity Health Of New England Supervisor/Preceptor:*

Trinity Health Of New England Department Coordinator:*

Rotation Start Date*

Rotation End Date*

The above signee has applied to participate in a training program through Trinity Health Of New England Corporation, Inc. (TH Of NE) in Hartford, Connecticut. He or she understands that execution and submission of this Participant Acknowledgement Form is a pre-condition to commencing participation in the training program at TH Of NE. Learners will not be eligible to engage in training at TH Of NE until all forms have been received, reviewed, and approved. Prior to commencing training activities at TH Of NE, he or she shall complete the New Learner Orientation and Onboarding Process required by TH Of NE. This includes the following:

The Participant Acknowledgement Form and Rotation Schedule – complete electronically above
The Learner Mandatory Orientation Sign-Off Sheet
The Clinical Experience Participation Agreement
The Code of Conduct and Integrity and Compliance Orientation Acknowledgement Statement
The Confidentiality and Non-Disclosure Statement
The Conflict of Interest Disclosure Form
Language Services Training Presentation and Sign-Off Sheet
Learner Health Clearance

PARTICIPANT ACKNOWLEDGEMENT FORM AND ROTATION SCHEDULE

LANGUAGE SERVICES TRAINING PRESENTATION SIGN-OFF SHEET