Trainee Personal Information

Please fill out this form completely.

First and Last Name *

email Address *

Phone Number *

Current Facility Employed *

Enter the date range you will be training at KRH. *

How many hours will you be training at KRH? *

Who is your facility contact? *

What is your facility contact's email address? *

What is your facility contact's phone number? *

KRH Contact or Preceptor Name or Department for this Training Experience *

KRH Contact's email or phone number if available or enter N/A. *

Emergency Contact Name *

Emergency Contact Phone *

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 EDU800 Policy *
Yes   No  

I understand and agree to allow my immunization records and background check to be shared between my current employer and Kalispell Regional Healthcare. *
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 to the right to certify your agreement to all the above. *

Other Comments or Information

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