Get Non Employee Registration Form

Completing the NON EMPLOYEE REGISTRATION FORM is an essential step for individuals seeking to engage in non-employed capacities at Lawrence + Memorial Hospital. This guide provides a clear and detailed walkthrough for filling out the form online, ensuring a smooth and efficient process.

Follow the steps to correctly complete the registration form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your full name in the designated field.
3. Fill in the current date to validate your submission.
4. Provide your complete residential address, ensuring accuracy for communication purposes.
5. Enter your telephone number and cell phone number, if applicable.
6. Input your date of birth in the specified format.
7. List your email address for further contact.
8. Fill in your Social Security number for identification purposes.
9. Indicate whom to notify in case of an emergency and provide their contact information.
10. Record your health insurance company and policy number, if you have coverage.
11. Specify the department or occupation that interests you.
12. Answer whether you are currently attending high school and, if yes, provide the name of the school and your anticipated graduation year.
13. Indicate your college enrollment status and, if applicable, detail the school and your intended area of study.
14. If you are currently employed, please specify your occupation and detail your interest in job shadowing the department noted earlier.
15. Complete the health information section, either by having your physician fill it out or by attaching the appropriate health records.
16. Provide proof of immunities, such as rubella and rubeola, along with dates.
17. List the results of your PPD test completed within the last 12 months.
18. If applicable, fill out the hepatitis B vaccine information and dates.
19. Indicate the date of your influenza vaccine.
20. Ensure a physician's signature is present along with their contact number.
21. Sign the non-employee agreement section, understanding the responsibilities outlined within.
22. If under 18, include a parent or guardian's signature and date.
23. Choose to save changes, download for your records, print, or share the completed form as needed.

Complete your non-employee registration form online today to get started!