I understand it is my responsibility to provide DRH Health with my current immunization records such as Measles, Hepatitis B, Mumps, Rubella, Influenza, and Chicken Pox (Varicella).

I also understand a current Tuberculosis skin test (PPD) is required along with the flu vaccine for this current season as required by DRH Health.

I have read and understand the information given. Should I need medical attention during or as a result of this job shadowing/internship experience, I assume full responsibility for any treatments deemed necessary. I assume responsibility of all medical costs which result and release DRH Health of all liability. I give the facility at which job shadow/internship is being conducted permission to release my telephone number or contact information to the requested department. While I am job shadowing at any DRH Health site, I realize that all healthcare information, patient/resident care and records are a confidential matter. All information exchanged while I am observing must be held in strictest confidence. I will only observe patient care and the role of the healthcare provider.

I have read and understand the information given and authorize my son/daughter to participate in this job shadowing/internship experience. DRH Health shall not be held responsible for adverse occurrences and/or outcomes. Should my child need medical attention during or as a result of this job shadowing/internship experience, I authorize such medical care and assume full responsibility for any treatments deemed necessary. I assume responsibility for all medical costs which result and release DRH Health of all liability. I give DRH Health permission to release my son/daughter telephone number or contact information to the requested department.