Student Internship Request Form

Salutation:
Student Name:
Home Phone Number:
Cell Phone Number:
E-mail Address:
Mailing Address:
City:
State:
Zip Code:
WFH Site:
WFH Department of educational experience:
WFH Manager/Contact Person
Number of hours required for your experience:
Start Date:
End Date:
Are you interested in housing provided by WFH? If yes, indicate arrival date and time:	YesNo
College/School Name:
Health Occupation Area of Study:
Programs:
Level of Education
Anticipated Graduation Date:
Instructor's Name:
Instructor's E-mail Address:
Instructor's Phone Number:
In Case of Emergency, Notify:
Relationship:
Phone Number:
Address:
City:
State:
Zip Code:
Comments:

I understand and agree that at no time will any information regarding patients or operations of WFH be revealed to anyone other than those authorized to receive it. I understand that the giving of the information concerning a patient, associate, or the operations to those not authorized to receive such information is unlawful and shall be sufficient cause for immediate termination of the educational experience.

I agree to any necessary health screening and orientation required by the hospital and understand my assignment is contingent upon successful completion.

I understand I should not participate in this experience if I am unhealthy or have a communicable disease (temperature > 100 degrees) which may endanger patients.

I agree to hold Wheaton Franciscan Healthcare harmless for any and all injuries arising out of and in the course of my education al experience not caused by the fault of WFH or its associates.

I agree to dress in a manner reflective of the dress code policy and conduct myself in a professional and safe manner at all times.I understand that appropriate identification is required at all times during my educational experience.

I understand I will be under direct supervision at all times and will follow my supervisor¡¯s instructions.

I will never bring any controlled substance, including liquor, narcotics, or nicotine onto the premises.

This agreement is effective for the duration of the educational experience.

By clicking here I agree to all of the terms of the agreement stated above.