Please complete this application form if you are interested in participating in our Emergency Room Shadowing Program. Once you complete the form, click the submit button at the bottom.

Your Information

Emergency Contacts

Reason for Shadowing

Anything Else You Would Like Us to Know?

How Did You Hear About Our Program?

Prior to shadowing, I will:

I will show evidence of proof of immunity (signed by a healthcare provider to Measles, Mump, Rubella, and Varicella. I will provide results of two negative TB screenings done within the past year. I will complete the "Shadowing Expectations" form. I will sign a "Job Shadower Consent and Release of Liability Form" at my placement interview.