BismarckMedX In Person

MedX Sessions

Please select the sessions you would like to attend:

You may select as many sessions as you want.

October 5: Pharmacy & Sterile Processing

November 2: AirMed: Flight Nursing &Paramedic

December 7: Respiratory Therapy

January 4: Physical/Occupational/Speech Therapy

February 1: Long Term Care & Nursing

March 7: Medical Laboratory

April 4: Radiologic Technology

Student Information

Please provide the following student information:

What is your full name?*

What is your email address?*

Please do not use a school email address.

What is your cell phone number?*

Phone

What is your street name/number?*

What is your town/city?*

What is your state?*

Select

What is your zip code?*

What is your date of birth?*

Parent/Guardian Information

Please provide the following parent/guardian information:

What is your parent/legal guardian's full name?*

What is your parent/legal guardian's cell phone number?*

Phone

What is your parent/legal guardian's email address?*

If applicable, what is a secondary parent/legal guardian's full name?

Optional

If applicable, what is a secondary parent/legal guardian's cell phone number?

Optional

Phone

If applicable, what is a secondary parent/legal guardian's email address?

Optional

School Information

Please provide the following school information:

What is the full name of your school?*

Please select your grade for the upcoming school year:*

10th

11th

12th

Extracurricular Involvement

Please provide the following extracurricular involvement information:

Are you involved with any extracurricular programs or clubs?

Examples: HOSA, DECA, FCCLA

Personal Statements

Please provide the following personal statement information:

Please describe your interest in health and medical careers.*

What do you hope to gain from participation in the MedX program?*

How did you hear about the MedX program?*

Student Confidentiality Statement

Please read the each statement carefully and check the box if you agree to the statement:

I acknowledge that Sanford Health is providing me with access to individuals and facilities where individually identifiable health information is protected by state and federal laws and regulations and the policies and practices of Sanford Health.*

I acknowledge that consistent with the agreed-upon purposes of my participation, I will not deliberately seek to learn the identity of patients or obtain information about their medical treatment or condition.*

I acknowledge that consistent with the agreed-upon purposes of my participation I will not release, discuss, or remove from the premises any individually identifiable health information in any form acquired during my event, incidentally or otherwise, except with the authorization of the person to whom the information pertains.*

I acknowledge that consistent with the agreed-upon purposes of my participation, I will not interact with patients, conduct interviews, take photographs, or make audio or video recordings without permission.*

I acknowledge that consistent with the agreed-upon purposes of my participation, I will respect any limitations on the use or disclosure of individually identifiable health information expressed by any patient, (or their legal representative) verbally or in writing.*

I acknowledge that consistent with the agreed-upon purposes of my participation, I will maintain appropriate decorum and cooperate fully with requests or directions by physicians or staff to assure minimal disruption of normal operations during my event.*

I acknowledge that consistent with the agreed-upon purposes of my participation, I will not discuss or release any intellectual/proprietary information regarding Sanford Health.*

If the participant is under the age of 18

If participant is under the age of 18, a parent/legal guardian must read below and consent by checking the box

As the parent/guardian of a participant in this program, I understand and consent to the audio/video recording of my child while participating in this program, and understanding that a recording of this event may be used for publication, telecast, advertising, education and/or publicity purposes by Sanford.

Re-contact Statement

Please read the statement carefully and select your answer:

I allow Sanford Health to access this information and re-contact me for future events and employment.*

Yes

No

Are you interested in employment opportunities at Sanford Health / Good Samaritan Society*

Yes

No