Children"s of Alabama - Security Badge Request

Children's of Alabama - Access Request

Welcome to Children's of Alabama. We want to make your arrival as easy as possible. You will need to complete a separate registration form for each individual who will need access to our facilities, security badge or parking access. If you have any questions about registration, please call 1-205-638-9682.

This form is required for all new staff or affiliates at Children's to receive your ID badge. If you are not an employee or medical provider and will use our network, the additional Affiliate Form must be complete prior to a your arrival to create a CHS account. Please work with your COA contact to be sure all forms are complete at least one week prior to your arrival at our facility.

This form is not intended for short term visiting observers. Please check in at the Information Desk upon arrival to obtain a Visitor's pass.

On-site PALS training no longer requires a permanent badge. Please check in at the Visitors Desk upon arrival to obtain a one-day access sticker.

General Information

Type of Request*

I am a new arrival.I am returning to Children's of Alabama after a gap in time and need to be reactivated.I am currently at Children's of Alabama and need an update or change on my profile.I need a replacement badge with no changes.

Legal Name*

First NameMiddle NameLast NameSuffix (no period)

Relationship to COA*

Date of Birth*

Date of birth must be accurate to prevent duplicate records in our network

Contact Information

If you are not our employee, please provide your work address as your Primary Street Address.

Primary Address Type*

Secondary Address Type*

Primary Street Address*

Street Address

Street Address Line 2

CityState

Zip Code

Secondary Street Address

Street Address

Street Address Line 2

CityState

Zip Code

The following contact information will be used for emergency notifications.

If you have a non-COA work email address, please provide it as your Primary Email Address.

Primary Email Type*

Primary Email Address*

This must be a valid email address so we can contact you.

Secondary Email Type*

Secondary Email Address

Primary Phone Type*

Primary Phone Number*

Secondary Phone Type*

Secondary Phone Number

COA Role Information

Start Date*

End Date if known

Department Name*

Dept Phone Number

Supervisor or COA Contact*

Supervisor or Contact Email Address*

Scheduled Hours Per Week

Scheduled Days Per Week

ID Badge/Org Information

Full Preferred Name

The name you go by

Role or Title*

Role at COA

Clinical Certification/Degree*

NPI Number, If Applicable

Specialty

Sub Specialty

School Attended, if Applicable

MD Student Year, if applicable

Check if you ever previously had access to CoA.

True

Check if you have a badge or parking decal from prior access.

True

School or Organization Sponsor

If applicable, such as affiliate student/intern

Sponsor Email Address

Current or Former COA ID, if known

Choose a PIN for Secure Area Access*

4 digits

Please describe what you will be doing at Children's that requires a security badge*

0/500

Please attach a badge photo up to 5 mb in size and in one of these file formats: png, jpeg, jpg

If you are not able to submit a badge photo on this form, you will need to contact the security office 2-3 days prior to arrival at 1-205-638-9682 to schedule a photo time.

Vehicle Information

The following fields are needed for all employees or affiliates who will need to use staff parking.*

I will need to use staff parking at CoAI choose to opt out of staff parking at CoA

1st Vehicle Make

1st Vehicle Model

1st Vehicle Year

1st Vehicle Color

1st Vehicle Tag Number

2nd Vehicle Make

2nd Vehicle Model

2nd Vehicle Year

2nd Vehicle Color

2nd Vehicle Tag Number

Parking Payment Method (payroll option available only for direct COA employees)*

PayrollCheck

Payroll deduction option is only available to employees who are on the Children's of AL payroll.

Please note, you will need to be connected to the internet to submit this form from a device.

Admin Note