Hello! This application is ONLY for Fayette County Public Schools Southside Technical Health Sciences Practicum who have been identified by Mrs. Jones and Mr. Morrison. Thank you.

Student Contact Information

NOTE: Please enter your cell number for your primary phone number.

First name:

Last name:

Street 1:

Street 2:

City:

State:

* Zip: *

Primary phone:

Email address:

Please list any family member names who are employed here at Baptist Health Lexington.

Student Parent Contact Information

First name:

Last name:

Cell phone:

Email address:

Relationship:

Emergency Contact*

*Complete this section only if someone other than your parent is your Emergency Contact.

First name:

Last name:

Cell phone:

Email address:

Relationship:

Student Personal Information

Please select "Current School Year" you are enrolled in at the time of submitting this application.

Date of birth:

Age:

Gender:

Current School Year:

Southside Practicum Student Agreement

By submitting this application, I am agreeing to the following if I am selected:

Abide by Baptist Health Lexington Hospital's policies and procedures.

Volunteer/Observe in my assigned area of the hospital.

Follow Baptist Health Lexington's Dress Code requirements found in student's orientation packet.

Follow Baptist Health Lexington's handwashing guidelines and our other sanitation procedures.

Maintain the highest level of confidentiality when discussing patient and other hospital matters ONLY as it relates to my volunteer/observation assignment duties.

I Agree