Student Personal Information

Please fill this form out completely.

First and Last Name *

Today's Date *

email Address *

Phone Number *

Are you a current Kalispell Regional Healthcare employee? *
Yes   No  

If so, where? If not, type N/A *

Have you ever had KRH computer access under a different name? *
Yes   No  

If yes, name computer access was under if no, type N/A? *

Will you be over the age of 18 when you begin your student experience? *
Yes   No  

School Attending *

Program Enrolled In *

What academic rank is this program? *
Non-Credit   Certificate   Licensure Training   Associate of Applied Science   Certificate of Applied Science   Associate of Arts   Associate of Science   Bachelor of Arts   Bachelor of Science   Master's Degree   Doctorate   Medical Doctor (MD)   Doctor of Osteopathy (DO)  

KRH Department(s) you will complete your student clinicals. *

Please list the college course number(s) you will be attending for clinicals.

Rotation Start Date *

Rotation End Date *

What is the minimum number or hours you need to complete for this rotation? *

Advisor, School Contact or Instructor Name *

Advisor, School Contact or Instructor email *

Advisor, School Contact or Instructor Phone Number *

KRH Preceptor Name *

Emergency Contact Name *

Emergency Contact Phone *

Vehicle Information #1 Make: Model:Color:Year:State:License Plate # if known. *

Vehicle Information #2 (if necessary)

AcknowIedgment that I have read and understand the KRH Code of Conduct

I agree to obey all federal, state and local governmental laws and regulations at all times. If I am not certain about KRH's policies, or about the law, it is my responsibility and my right to get advice from my supervisor, human resources, any management personnel, general counsel or the compliance officer.

I agree to comply fully with the Compliance Program guidelines contained in the Code of Conduct document. I understand that compliance with these guidelines is a condition of my association with KRH. Likewise, I understand any failure to report a violation (even if the violation is committed by another individual), can result in disciplinary action, up to and including termination of my student experience. I also understand that KRH reserves the right to occasionally amend, modify and update these Compliance Program guidelines.

I also acknowledge that the Code of Conduct is only a statement of principles for individual and business conduct and does not, in any way, constitute an employment contract or an assurance of continued association.


My signature on this form acknowledges that I have reviewed the Kalispell Regional Healthcare (KRH) Code of Conduct and agree to abide by its contents. Please type your full name. *

I have read and met, or will meet, prior to my start date, all the obligatory immunizations, background checks, documents and all other requirements mandated by Kalispell Regional Healthcare (KRH) in the orientation manual. *
Yes   No  

I have read and understand the Acknowledgement of Resources *
Yes   No  

I have read and understand the Confidentiality Acknowledgement *
Yes   No  

I have read and understand the Disclaimer for Intellectual Property. *
Yes   No  

I have read and understand the Security Codes and Procedures
Yes   No  

I have read and understand the EDU800 Policy. *
Yes   No  

I have reviewed the Dress Code Policy HR 530d and agree to abide by those standards. *
Yes   No  

I understand and agree to allow my immunization records and background check to be shared between my school and Kalispell Regional Healthcare and all its entities as needed for my student experience clearance. *
Yes   No  

Signature: The information contained on this form is correct and complete to the best of my knowledge. Type your name in the box below to certify your agreement to all the above. *

Other Comments or Information

Are you a new or returning student at KRH? *
New   Returning