Tours Under 2 Hours

This form must be fully completed at least one week prior to the tour date. When you hit "submit" it will be automatically emailed to the Logan Health Student Affiliations Department. Prior to the tour, a roster of all who have filled out the form will be provided to the hosting department to ensure permission to attend. 

If you are under the age of 18, the TOURS AND LIMITED OBSERVATION form on the website must be printed out and signed by a legal parent or guardian.

Participant First and Last Name *

Participant email Address *

Phone number *

Date of Birth *

Emergency Contact *

Emergency Contact Phone *

Primary Physician *

Date of Tour *

Department Touring *

School/Organization *

Program Name *

Program Leader/Instructor *

Program Leader/Instructor Phone *

Program Leader/Instructor email *

Confidentiality Acknowledgement: In the course of my learning experience, I understand I may be exposed to private and confidential information about Logan Health System (LH) patients and employees. I understand that this information may NOT be shared outside of the program setting with any member of the public, friends or family. The intentional breach of confidentiality regarding patients and/or organization employees is considered gross misconduct and reason for termination of the learning experience and may subject me to personal liability. Having understood the above, I do hereby agree to maintain confidentiality of all information to which I may be exposed during my learning experience.

Confidentiality Acknowledgement *
I Agree  

Disease Prevention: I understand that I should not attend the tour if I am ill, coughing or have nausea, diarrhea or a fever. I will also help prevent the spread of germs by washing my hands and/or using an alcohol-based hand rub between departments and as needed during the tour. Hand hygiene is the single, most effective method for prevention of infection. I also understand that I am not to attend if I am ill, coughing or have a fever.

Disease Prevention Acknowledgement *
I Agree  

I hereby give my consent, in the event of injury or illness, for emergency medical/dental treatment, hospitalization or other treatment as may be necessary for the welfare of the observer by a physician, dentist, licensed nurse and/or other hospital employee during all periods of time in which I am observing at Logan Health. Further I hereby waive, on behalf of myself any liability of Logan Health, its agents and employees, arising out of such medical treatment. I understand I will be responsible for any charges incurred for any such treatments.

Medical Release Acknowledgement *
I Agree  

Dress Code: I have been informed of the Logan Health dress code and will abide by it. If you need a copy of this document please ask you instructor or The Logan Health Student Coordinator for the most recent version. *
I agree  

Signature: The information contained on this form is correct and complete to the best of my knowledge. Type your name in the box below to certify your agreement to all the above. *