MedX Virtual 2022

This is the MedX Virtual application form. Please fill out this application form to the best of your ability.

Student Information:

Please provide the following student information:

First name:

Last name:

Cell Phone

Phone

Email address:

Street address

Town/city:

State:

Zip code:

Date of birth:

mm/dd/yyyy

Student School Information

Please provide the following student school information:

What is the full name of your school?

How did you hear about the MedX program?

Extracurricular Involvement

Please provide the following extracurricular involvement information:

Please describe the school, community, or religious activities and organizations with which you are involved.

Are you currently employed?

Yes

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?

Have you, or are you currently participating in any medical/health career education programs in school or elsewhere?

If yes, please describe the programs.

Please name three (3) of your strengths that would make you well suited for a career in the health care field.

Parent/Guardian Information

Please provide the following parent/guardian information:

Primary parent/guardian full name:

Primary parent/guardian cell phone number:

Phone

Primary parent/guardian email address:

Secondary parent/guardian full name:

Secondary parent/guardian cell phone number:

Phone

Secondary parent/guardian email address:

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 virtual visit, 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 virtual visit, 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 virtual visit, 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 virtual visit, 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 virtual visit, 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 virtual visit, I will not discuss or release any intellectual/proprietary information regarding Sanford Health

Virtual Video/Audio and Recording Statement

This program will be conducted virtually and will be recorded and made available for the general public to view at a later date. As a virtual participant in the program, your audio and video may be included in the recording of this program. By registering for and participating in the program, you agree to allow your audio and video participation to be used for publication, telecast, advertising, education and/or publicity purposes by Sanford. By checking the box to the right, I acknowledge that I have read, understood and agree to the above statement.

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

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