I understand that it is my responsibility to provide Duncan Regional Hospital with my current immunizations such as Measles, Hepatitis B, Mumps, Rubella, Influenza, and Chicken Pox (Varicella).

I also understand a current Tuberculosis skin test (PPD) is required. I give consent to receive a PPD skin test and will return to the DRH Team Member Health Nurse in 48-72 hours for a reading of test results. I further understand that if I do not return for reading, the test is void and will have to be repeated.

I have read and understand the information on the Information Sheet. Should I need medical attention during or as a result of this job shadowing experience, I assume full responsibility for any treatments deemed necessary. I assume responsibility of all medical costs which result and release Duncan Regional Hospital of all liability. I give the facility at which job shadow is being conducted permission to release my telephone number or contact instructions to the requested department. While I am job shadowing at any Duncan Regional Hospital 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 on the Information Sheet and authorize my son/daughter to participate in this job shadowing experience. Duncan Regional Hospital 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 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 Duncan Regional Hospital of all liability. I give Duncan Regional Hospital permission to release my son/daughter telephone number or contact information to the requested department.