Post Secondary Placements All post-secondary students are required to complete this form. Apply Online Thank you for completing the online orientation program. It has provided you with important information pertaining to your student experience at Brightshores Health System. Please ensure that you have reviewed the orientation modules carefully, as it is expected that you will know the information for your time spent at Brightshores. It is also expected that you will remain up to date on policies and procedures while on-site at Brightshores.Personal information on this form is collected under the authority of the Public Hospitals Act, Reg. 965, and will be used for the purposes of student placement and to facilitate compliance with public hospitals' legislated accountabilities at Brightshores Health System.Contact Information - Student ProfilePlease provide your contact information*First NameMiddle Initial*Last Name*Home Address*City*Province*Postal Code*Cell Phone*Home Phone*EmailEmergency ContactWho should we contact in case of an emergency?*Emergency Contact Name*Emergency Contact Relationship*Emergency Contact Cell Phone*Emergency Contact Home Phone*Emergency Contact EmailEducation and Placement*School / Educational InstitutionChoose your School Brescia College Algonquin College Athabasca University Brock University Bruce Peninsula District School Cambrian College Canadian Career College Centennial College Centre for Distance Education Collingwood Collegiate Institute Conestoga College Dalhousie University Durham College Everest College Fanshawe College Fleming College George Brown Georgian Bay Community School Georgian College Georgian College Bridging Georgian/UOIT Grey Highlands Secondary School HealthCareCAN Humber College John Diefenbaker Senior School Kincardine District Secondary School Lakehead University Lambton College Laurentian University Laurentian/McMaster Loyalist College McMaster University Medix College of Health Care Mohawk College Nipissing University Owen Sound District Secondary School Oxford College Peninsula Shores District School Queens University Renison College Ryerson University Saugeen District Secondary School Seneca College of Applied Arts and Technology Sheridan College St. Clair College St. Marys High School St.Lawrence College St-Clair College Trent University University of Guelph University of Ontario Institute of Technology (UOIT) University of Ottawa University of Toronto University of Waterloo University of Windsor Walkerton District Community School Western University Wilfrid Laurier University York University Other - specify below Other school not listed*Year / Semester*StatusSelect your Status New Post Secondary Student GBHS Staff Nursing Instructor *Field of StudyChoose your field of Study Addictions Biomedical Engineering Cardiology Technology Clinical Pastoral Education Dietetics Health Information Management Medical Laboratory Assistant/Technician Medical Laboratory Technologist Medical Radiation Technology Midwifery Nurse Practitioner Nursing - BSCN Nursing - RPN Nursing - RPN to BScN Bridging Occuational Therapy Assistant Occupational Therapy Office Administration Pharmacist Pharmacy Assistant/Technician Physical Therapy Assistant Physiotherpy Recreation Therapy Respiratory Therapist Social Work - Bachelor BSW Social Work - Masters MSW Speech Language Pathology Ultrasonography Other - specify below Other field of study not listed*Placement Start Date*Placement End Date*Unit / Department you are placed onChoose your Department Administration Ambulatory Care Biomedical Engineering Business Office Clinical Nutrition Community Stroke Rehab Team Critical Care/Intensive Care Unit Day Surgery Diabetes Diagnostic Imaging X-Ray Diagnotic Imaging Cardiology/EDS Diagnotic Imaging MRI Dignostic Imaging Ultrasound Emergency Engineering Services Environmental Services Food Services Health Records Infection Control Information Technology Laboratory Medical/Surgical Medicine Mental Health Services Inpatient Unit 4-5 Mental Health Services Inpatient Unit 4-6 Mental Health Services Outpatient Occupational Therapy Oncology Operating Room PACU (Recovery Room) Pharmacy Physiotherapy Rehabilitiation and Restorative Care Respiratory Spritiual Care Surgery Withdrawal Management and Addiction Services Women and Child Care Unit (WCCU) Other - specify below Other Unit / Department not listed*Brightshores Hospital SiteChoose your Site Markdale Meaford Southampton Lions Head Wiarton Owen Sound *Type of PlacementChoose your Type of Placement Group Placement - RPN Group Placement - BScN Praxis (RPN) Consolidation (BScN) Clinical Mentorship Field/Clinical Placement Internship Required DocumentsThe following documents are required to complete your placement package submission*Worker Health and Safety Awareness Certificate*Infection Control Module (screenshot)*Student Immunization Attestation*Police Record Check*IT Security Quiz (screenshot)*Privacy Quiz (screenshot)Acknowledgement of UnderstandingBy checking the box below, I agree that I have read and understand the policies and procedures and have completed all of the mandatory orientation modules required for my placement at Brightshores Health System. I have uploaded all required documentation to my student profile and will present the original copy of my valid Police Record Check to Learning Resources on my first day of placement. I can also attest that I do not have a current no trespassing order placed against me at Brightshores Health System.* I Agree COVID-19 AttestationI attest that I am fully vaccinated against COVID-19 and will screen for COVID-19 prior to each and every entry into the hospital for my student placement. I will screen for COVID-19 signs and symptoms following the signage direction listed at the hospital entry. I will follow current recommendations to ensure appropriate criteria have been met prior to return to placement. (Current recommendations include confirmation of a negative COVID-19 test and 24 hours symptom-free prior to return to placement.) I understand that I may contact the Occupational Health and Safety Department if I have any questions (519-376-2121 x2229)* I agree Fields with (*) are compulsory.
