Student/Observer Application

* Required Field
Emergency Contact
Yes No

Health Screen
Yes No

Yes No

Yes No

Yes No

Yes No

PLEASE NOTE: ProgressiveHealth reserves the right to terminate the observational experience of any person who shows signs of communicable disease. If you are suffering from a cold, flu, fever, stomach virus or other indicator of communicable illness, PLEASE CANCEL YOUR OBSERVATION AND RESCHEDULE.

ProgressiveHealth reserves the right to deny any application or to terminate the observational experience of anyone who provides inaccurate application information or fails to observe ProgressiveHealth standards and policies.

I understand if I knowingly have an infectious illness, fever, cough I will refrain from visiting until at which time my symptoms have improved and I am no longer infectious. I hereby certify the above information is true and correct to the best of my knowledge.

Clear

Signature

To sign:
Computer: Place mouse cursor in the box below. Click and drag the cursor, spelling your name.
Tablet/Phone: Use your finger to draw your name.