Basic Information*

Emergency Contact Info*

School Affiliation*

Program/Placement Coordinator & Contact Info*

Clinical Rotation Specialty Needed*

Student Degree Program*

Personal Biography*

Terms & Conditions*

• I authorize all educational institutions to release personal and professional information to Kintegra. I also consent to a criminal background search, if required. I further release Kintegra as well as those supplying said information, from any and all liability from these investigations.
• I understand that Kintegra holds every employee, volunteer and student accountable under HIPPA. Sharing information regarding patients, employees, or the clinic to those not authorized to receive it is unlawful and shall be sufficient cause for my immediate dismissal.
• I authorize Kintegra to complete a required health review to enter the clinical student rotation program. I will provide a recent (within 1 year) PPD (Tuberculosis Skin Test) result. I understand that any positive reaction to the PPD test may also be followed up with further testing.
• I understand that any false statements on this application to Kintegra may be considered sufficient cause for dismissal.
• I will provide Kintegra with sufficient notice regarding changes/absences from planned and scheduled work commitments.
• I agree to undertake (or provide evidence of within the last year) OSHA/HIPAA training, and job related training as necessary and as specified by Kintegra, at no cost to me.