Form

New Student Information

(SSN and DOB are REQUIRED for our security system in order to create your ID badge and grant computer access) PLEASE DO NOT PRINT THIS FORM - THIS IS AN ELECTRONIC FORM
Social Security Number *
Full Name (First Name, Last Name) *

First Name Last Name
Date of Birth *

Month Day Year

Current Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *
Your Email Address *
Emergency Contact *

First Name Last Name
Relationship to Student *
Emergency Contact Phone Number *
School/Affiliation *
School Contact *

First Name Last Name
School Contact Phone Number *
School Contact Email *
Are you employed by LVHN or any of its subsidiaries? *

Yes No
Please select an LVHN site
Experience Start Date at LVHN *

Month Day Year
Anticipated Graduation date/ Graduation Year *

Month Day Year
Program/Course Name *
Area(s) of Assignment (What department will you be working with?) *
Name of Preceptor
Gender

Female Male
Ethnicity/Race
Will you be participating in the Transitional Skills Unit (TSU)? *

Yes No
If participating in the TSU, have you been a Pennsylvania resident for the past two years?

Yes No
Have you been convicted of a misdemeanor or felony since your 16th birthday? *

Yes No
If yes, please explain.
Please Check All That Apply (If applicable, please send copy)

Healthcare Provider BLS (CPR) is current (This is required for Rehabilitation Services Dept.)
Please Check All That Apply (If applicable, please send copy)

If RN, must have valid certification
Please Check All That Apply (If applicable, please send copy)

If RN, must have professional liability insurance
PA Students only: Rotation Start Date

- Month - Day Year
PA Students only: Have you attended a previous rotation witg LVHN?
PA Students Only: Please upload headshot appropriate for use on your LVHN ID Badge
Orientation Verification

I have received instructions in the following areas relevant to my experience at LVHN.
I have received instructions in the following areas relevant to my experience at LVHN: Housing/Parking/Meals; Telephone/Pagers/Packages; Library/Computers/Printing; HIPAA/Ack of Confidentiality/PRIDE; Dress Code/Hand Hygiene; Social Media Policy; Code of Conduct; No Smoking Policy; Employee Incident Reports; Rapid Response Team; Patient Identification/Patient Safety/Patient Rights; Illness/Emergencies/Restraint & Seclusion Policies; Fall Prevention/Stroke Alert/Code Blue/Domestic & Relationship Violence; Blood/Bodily Fluids.Please check Box in Agreement *

Yes
By signing this form, I declare that I have supplied accurate and truthful information, I have completed the New Student Orientation, and I will follow all procedures as outlined by Lehigh Valley Health Network. *

First Name Middle Name Last Name
Date *

Month Day Year
Upload Course Objectives (optional)
Additional Comments:
Should be Empty:

New Student Information

Orientation Verification