New Student Contact Information

New Student Information

SSN and DOB are REQUIRED for our security system in order to create an ID badge, to longitudinally track learners through our Jefferson Health system, to grant computer access, and to contact you about opportunities within Jefferson Health. PLEASE DO NOT PRINT THIS FORM - THIS IS AN ELECTRONIC FORM. If you have questions regarding this form please contact Nora Alu at Nora.Alu@jefferson.edu or Davida Leayman at Davida. Leayman@jefferson.edu . Faculty & Employees do not complete this form. For faculty please contact Jennifer Newland at Jennifer.Newland@jefferson.edu. Employees need to complete the Employee Exemption Form.
Full Name (First Name, Last Name)*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Your Email Address*
Personal email here, school email collected later in the form
Phone Number*
Please provide your cell phone number.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sex*

FemaleMaleNonbinary/Gender XPrefer not to say
Pronouns*

She/her/hersHe/him/hisThey/them/theirsSome other pronounsPrefer not to say
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteSome Other RaceTwo or More RacesPrefer not to say
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoPrefer not to say
Program Major/Student Type*
Other Student Type
Please type in your program/student type
School/Affiliation *
Other School Name
Please type out the full name of your school
Please select LVHN site of program/experience
Program/experience Start Date at LVHN*

MonthDayYear
Anticipated Graduation Date/ Graduation Year*

MonthDayYear
Emergency Contact*

First NameLast Name
Relationship to Student*
Emergency Contact Phone Number*
School Contact*

First NameLast Name
School Contact Phone Number*
School Contact Email*
example@example.com
Are you employed by LVHN or any of its subsidiaries?*

YesNo
Area(s) of Assignment (What department will you be working with?)*
Name of Preceptor
Will you be participating in the Transitional Skills Unit (TSU)?*

YesNo
If participating in the TSU, have you been a Pennsylvania resident for the past two years?

YesNo
Have you been convicted of a misdemeanor or felony since your 16th birthday?*

YesNo
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
Physician Assistant Students only: Rotation Start Date

MonthDayYear
Physician Assistant Students only: Have you attended a previous rotation with LVHN?
Physician Assistant, Medical and Nurse Practitioner Students: Please upload a headshot with a plain background for your LVHN ID Badge

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New Student Orientation

Click here to review: LVHN Network Wide Orientation Modules
I have reviewed the LVHN Network Wide Orientation Modules*

Yes
By typing my name in the box below, I declare that I have supplied accurate and truthful information, I have completed the LVHN Network Wide Orientation Modules, and I will follow all policies and procedures as outlined by Lehigh Valley Health Network.*

First NameMiddle NameLast Name
Date*

MonthDayYear
Upload Course Objectives (optional)

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Additional Comments:
Email
example@example.com
Should be Empty:

New Student Information