Carolinas HealthCare System

MedCenter Air: Observer Application

Please list your objectives for your observer day below. This will allow our medical crew to better tailor your experience in order to meet your needs. Examples of objectives include: to learn more about flight and/or ground transport; to gain a better perspective of pre-hospital medicine; to learn more about trauma, complex cardiac, or pediatric patients; and others. Please also list any areas of special interest you have (i.e. research, trauma, OB) that you’d like to see while you’re with us.



* Indicates required information
Objectives * 
Contact Information
 
Name * 
Company * 
Street Address 1 * 
Street Address 2 
City/Town * 
State * 
Zip * 
Email Address * 
Phone Number * 
Date of Birth (mm/dd/yyyy)
Must be 18 years of age or older. * 
Current Weight (220lb limit) * 
Credential Level * 







If Other, please specify:

Base Location * 
Emergency Contact Information
 
Name * 
Address * 
City/Town * 
State * 
Zip * 
Email Address * 
Phone * 
Medical Information
 
Medical History * 
Allergies * 
MD Name * 
MD Phone * 
Dentist Name * 
Dentist Phone * 
I have read and understand all polices.
I realize that breech of this information
may hinder further educational opportunities
with Med Center Air and affiliated facilities. * 

 

Patient Confidentiality:
As a participant in the Med Center Air Observer Program you may be involved in direct patient contact or have access to privileged patient information. You are obligated to keep this information in strict confidence at all times per Federal and State HIPAA guidelines as well as CHS confidentiality policy(PR 140.02, Confidentiality of Patient / Employee information) .

Dress Code:
As a participant in the Med Center Air Observer Program you are expected to dress in a professional manner with clean and neatly pressed clothing. Recommended clothing includes: Sturdy leather boots (no heels, dress shoes or sneakers), Khaki or cargo pants (no jeans, shorts or scrubs), Oxford or golf shirt (no loud colors or logo’s) and additional clothing for cold weather (sweater, jacket, gloves, etc.). Observers are required to wear provided helmet and safety vest on all flights. I have received, read and fully understand the Patient Confidentiality and Dress Code information. I realize that breech of this information may hinder further educational opportunities with Med Center Air and affiliated facilities.

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