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BROWSE OTHERS (US) FORMS

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updated 05/15
LSU Health Sciences Center Library
Patron Registration Form
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
S
ECTION ONE --PERSONAL INFORMATION: (Please Print Clearly)
Full Name:________________________________________________________________ ID #:_____________________________
Last First MI Students/Faculty/Staff/Residents
Local/Home Address:_____________________________________________ City, State, Zip Code: ____________________________
Alternate Email: _______________________________________ Home Phone #: (________) ________________________________
(ex: GMail, Yahoo)
Department:_________________________________________ Alternate Phone #:(_________) ____________________________
Office or Business Address:________________________________________________________________________
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
S
ECTION TWO --AFFILIATION INFORMATION
LSUHSC:
School of Allied Health School of Dentistry
School of Graduate Studies
School of Medicine School of Nursing
School of Public Health
Other ______________________________
STATUS:
Student
Faculty ( Full-Time Part-Time Clinical Gratis)
Resident Fellow
Staff
Proxy Staff/Student Worker for _____________________________/_________________ (Faculty /Dept.)
Please circle your program:
Allied Health Medicine
L1 L2 L3 L4
Nursing Dental
BSN CARE RN to BSN MN/MSN DNS/DNP D1 D2 D3 D4 DH DLT
Graduate Studies Dept.: _________________________ Public Health Dept.: _________________________
Non-LSUHSC Patrons Tulane Medical Center:
School of Graduate Studies School of Medicine School of Public Health
Status:
Faculty Fellow Resident Student Staff TU Library barcode: ________________
Other:
Health Professional: License Type: _________________________ License #:______________________
Outside LALINC Patron
Courtesy Patron (approval required)
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S
ECTION THREE -- PATRON RESPONSIBILITY STATEMENT:
I agree to observe all library regulations; to be responsible for all library materials checked out with this card; to pay charges for all lost
or damaged materials; to immediately report loss of card or incur liability for its misuse. I understand that any abuse of library
regulations may result in suspension of privileges.
Signature:____________________________________ Date:_______________
CPSC CLS COMD OMT OT PA PT RC
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Completed 6 April 2021

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