Please complete this application form if you are interested in a Job Shadowing or an unpaid internship opportunity at MUSC Health Florence and Marion Medical Centers. Once you complete the form, click the Continue button at the bottom.



Important Documents to obtain

Copy of government issued photo ID.

Proof of MMR vaccination or immunity to measles, mumps, rubella.

Proof of negative TB Skin test results within past 12 months. 

Proof of personal health insurance.

Drug screening test ( Free of charge).

Background check ( at the candidate's expense).



Name and address


Demographic Information


Emergency Contact Information

Please provide a contact information in case of emergency



Availability

Please indicate the days and times you are usually available to Shadow or do your internship.



Have you ever worked at a hospital?

If yes, please list the name of the hospital you worked or volunteered at and your role:



Do you require any accomodations under the ADA?


Criminal History

Have you ever been convicted of, or pled guilty to a criminal offense (misdemeanor or felony)? We conduct a criminal background check.



References


Your Goal

Please share what you hope to gain from this experience in the box below



Confidentiality Statement

I understand that information concerning patients, their illness, or their families is private. I preserve this right to privacy by not discussing their conditions, treatments, or any other private matters in public settings either in the hospital or outside of the hospital. 

Any information obtained from the patients medical record will be used only for authorized purposes. I will preserve and protect contents of the records and any other confidential information obtained. information concerning employees and their records is private and confidential. I understand that this private information shall be distributed only to authorized personnel. Financial information of patients, employees, or the organization shall be distributed only to authorized personnel. 

Computer access codes are recognized as electronic signatures to access automated patient and employee records. I understand that due to the confidential nature of the documentation in the medical record, my password should not be shared with another person. I hereby agree not to reveal my password, nor will I attempt unauthorized access to the system. if I suspect the security of my password has been compromised, I agree to report this to the Security Administrator immediately.

I understand that any violation of these rules of confidentiality may cause my association with MUHA to be terminated. I understand that a breach in confidentiality may be in violation of federal HIPAA and/or state statutes and regulations, and subject to prosecution under the law. 

I understand that I will be required to present my immunization records to be cleared for shadowing or Internship programs. 




Consent

I certify that all statements made in this application are true. I understand that the Medical University of South Carolina reserves the right to accept or reject my application on its sole discretion. 

I agree to notify the office of Volunteer Services of any allergies or other physical, mental, or emotional condition that might limit the participants ability to safely participate in this program. 

I agree to assume the costs of any injury or emergency occurred during performing my duties, if any such costs are incurred. 

I, the undersigned, for and in consideration of the benefit to be derived by participation in the Job Shadowing or Internship program, do hereby release and forever discharge Medical University Hospital Authority (MUHA), The Medical University of South Carolina (MUSC), their affiliates, agents, servants, representatives and staff from and against any and all liability and responsibility for any allergies, injury, illness, or sickness which may result from participation in the Job Shadowing and/ or Internship Program, and do hereby further agree to indemnify and hold harmless MUHA, MUSC, their affiliates, agents, servants, representatives and staff from any and all liability in such regard.