Student Safety / Compliance / Privacy Pledge Form

Prior to your first clinical date at St. Anthony, please complete the Student Safety / Compliance / Privacy Pledge form below.

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All fields marked with * are required.

Student Signature and Attestation Page

First Name *

Last Name *

Email Address *

Expected Student Experience Start Date *

Expected End Date *

Safety and Privacy

I acknowledge that I have read and understand the information provided in the St. Anthony Student Orientation packet. I have asked my preceptor to clarify any questions. *

I recognize the importance of maintaining the confidentiality of patients and residents at St. Anthony Regional Hospital and Nursing Home, and of assuring their right to privacy. *

I, therefore, pledge that I will not divulge any information about a patient or resident with persons in or out of the hospital or nursing home facilities unless the other party has a professional need to know.

I understand that St. Anthony may require my educational institution to attest to my criminal history background prior to me being permitted to participate in the program at St. Anthony.

I agree to disclose any change in status to criminal background history and understand that such changes in status may preclude my ability to participate in the program at St. Anthony.

By typing your full name, you attest to the validation of your responses above:

Type First and Last Name *

Enter Today's Date *