Student Experience Request Form

Story County Medical Center is delighted that you have chosen us to be a part of your healthcare education experience. To ensure that our patients are protected and students are well prepared, we require all students to complete organizational requirements prior to beginning their student experience at Story Medical. In addition, students must be at least 16 years old by the date of their experience. You will find the steps you need to continue your student journey below:

Complete the Student Experience Request Form below at least 4-6 weeks prior to the requested observation date. Your request will be sent to the Education Department, and they will contact you with additional information. Please note: Student Experience Requests are accepted based on department availability to accommodate the request.
Once the Student Experience request has been approved and scheduled, you will be provided required documents to review and complete.
After reviewing all documents, print and sign the Student Experience Attestation Form and Confidentiality Agreement. If you are under age 18, a parent or guardian will also sign the attestation form.
The required paperwork needs to be completed and submitted prior to the scheduled experience date.
Your first day onsite you will be provided a temporary badge to be worn at all times during your student experience. You will turn the badge into Education or leave with the department leader when your experience is complete.

To ensure that our patients are protected and students are well prepared, we require all students to complete organizational requirements prior to beginning their student experience at Story Medical.

Application

First and Last Name

Phone Number

Email Address

Date of Birth

Address

School/Organization

Major (if applicable)

Purpose of Observation

Total Number of Observation Hours Requested

Days and Times You Are Available to Observe

Other Area of Interest