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:

* 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:

Current School Attending:

Level of Education:

What Grade?:

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:

Zip:

Home phone:

Work phone:

Cell phone:

Email address:

Relationship:

Reason for Shadowing

* Reason for Shadowing:

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?

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