STUDENT ID BADGE FORM Name of Student:
First
Middle
Last
(please print)
Date of Birth: (Format - mm/dd/yy) Month:
Telephone #: Name of School Affiliation/Program: Clinical Rotation Dates:
Begins:
Day:
Year:
Ends:
As a student on clinical rotation at Harnett Health System, I understand and agree that the ID badge issued is to be worn above the waist and visible at all times in addition to school ID badge when on campus. I also understand and agree that the badge will be returned to Human Resources at the end of each rotation. I understand there is a $10.00 deposit for each badge. If badge is not returned, lost or stolen the $10.00 deposit will be forfeit. Student’s Signature: ________________________________________ Date:___________________
FOR OFFICE USE ONLY Date ID badge issued: ______________________________ HR Representative: __________________________________________Date:____________________
Revised: 11/2016
