Job Shadowing Application
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
First name:
*
Last name:
*
Street 1:
*
Street 2:
Street 3:
City:
*
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip:
*
Home phone:
OK to call me here
Work phone:
OK to call me here
Cell phone:
OK to call me here
Email address:
*
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
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19
20
21
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23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
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1957
1956
1955
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1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Current School Attending:
Choose
....Not Currently in School
...Other
Asbury College
Bardstown High School
Bath County High School
Beaumont Middle
Berea College
Berea Middle/High School
Bethlehem High School
Bluegrass Community Technical College
Bryan Station High School
Centre College
Christ The King
Crawford Middle School
Dunbar High School
East Jessamine High School
East Jessamine Middle School
Eastern Kentucky University
Eastside Vocational
Frankfort Christian Academy
Frederick Douglass HS
Garrard County High School
George Rogers Clark HS
Georgetown College
Henry Clay High School
Home School
Jessie Clark Middle
Lafayette High School
Lexington Catholic High School
Lexington Christian Academy
Lexington Community College
Lexington Trad. Magnet High Schoo
Lexington Trad. Magnet Middle Sch
Madison Central High School
Madison Middle
Madison Southern High School
Mary Queen
Maysville Community and Technical
Menifee County High School
Montgomery County High School
Morehead State University
Nelson County High School
North Laurel High School
Northern Kentucky University
Other
Sayre
Scapa Bluegrass
Scott County High School
Scott County Middle School
South Laurel High School
Southern Middle
Southside
St. Peter and Paul Middle School
STEAM Academy
Sullivan University
Sunshine Academy
Tates Creek High School
Tates Creek Middle School
The Lexington School
Thomas Nelson High School
Transylvania University
Trinity Christian Academy
Trinity High School
University Of Kentucky
University of Louisville
West Jessamine High School
West Jessamine Middle School
Western Kentucky University
Winburn Middle School
Woodbridge Academy
Woodford County H.S.
Woodford County Middle
Level of Education:
Choose
College
High School (Currently)
High School (Previous)
Middle School
Post Graduate
Trade/Vocational school
What Grade?:
Choose
10th
11th
12th
7th
8th
9th
Freshman (College)
Junior (College)
Other
Post Graduate
Senior (College)
Sophomore (College)
Major/degree:
Last 4 SSN:
Still in school?When will you graduate?:
Emergency Contacts
First name:
Last name:
Street 1:
Street 2:
Street 3:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Home phone:
Work phone:
Cell phone:
Email address:
Relationship:
Choose
Faith Community Member
Friend
Neighbor
Other Relative
Parent/Guardian
Shadow Sponsor
Son/Daughter
Spouse/Partner
Reason for Shadowing
*
Reason for Shadowing:
Community Service
Consulting Services
Job Investigation
Outside Activities
Professional Development
School/Class Requirement
If you have indicated any of the above, please explain the requirements of your shadowing experience:
Anything Else You Would Like Us to Know?
How Did You Hear About Our Program?
How did you hear about our program?:
Another volunteer
Church
College Campus/College Advisor
Corporate Outreach
Employee Referral
Friend
Government Program
High School
I am an employee of this hospital group
JCTC
KTAP Program
Newpaper Ad
None Given
Other
Physician
Recruitment Fair
Self Inquiry
Signs in hospital
United Way
Volunteer Match
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.
I Agree
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