Career Exploration Application Form

Please complete this application if you are interested in Career Exploration at MUSC Health.

*Note: Applicants are to identify a sponsor before applying for any of the Career Exploration programs.

*Note: Applications must be submitted a minimum of one month prior to desired start date.

*Note: Applicants are NOT to begin their program until their application has been approved by Career Exploration.

Once you complete the form, click the submit button at the bottom. Applications will be screened and selected candidates will be contacted directly prior to beginning the program. Please allow a minimum of one month for this process. Due to the volume of applications we receive we are unable to place every applicant. Thank you for your interest in Career Exploration at MUSC!

Contact Information

Please complete this application form if you are interested in Career Exploration at MUSC Health.

First name:

Last name:

Middle name:

Title:

Preferred Name:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Cell phone:

Email address:

Demographics and Personal Information

Date of birth:

Gender:

Level of Education:

Current school attending:

Grade Level:

Ethnicity:

Social Security Number:

Still in school?When will you graduate?:

Emergency Contact

1

2

First name:

Last name:

Street 1:

Street 2:

Street 3:

City:

State:

Zip:

Cell phone:

Relationship:

Do you require accommodations under the ADA?

If yes, please explain:

Program

Full descriptions of our programs are available on our website. We offer five programs:
Job Shadowing
Observation
Mentoring
Clinical Sponsorship
Visiting Practitioners

Desired start date:

Desired end date:

Please indicate which of the five programs you are applying for:

Sponsor Information

Please provide us with the name and contact information of your MUSC sponsor:

Sponsoring Department Information

Please provide the name of the department:

Skills & Experience

Please check all that apply:

HS student enrolled in a Health Science Program?

Anticipated program/major?

Receiving college credit for Career Exploration?

If yes, please describe the course requirements.

Location for Career Exploration

Locations are at the discretion of the Hospital.

MUSC location you are applying for: 1)Charleston.... 2)Lancaster... 3)Marion... 4)Florence... 5)Chester...

Criminal History

Have you ever been convicted of, or pled guilty to a criminal offense (misdemeanor or felony)? You will be required to provide a criminal background check. Falsification of this or any other information on the application is grounds for immediate termination.
*A conviction does not necessarily disqualify you.

Have you ever been convicted?:

YES

If Yes, please explain:

Confidentiality and 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.

Some areas of the MUSC campus are potentially hazardous environments. Even under ideal conditions, including the proper use of materials and adherence to safety procedures, a risk of personal injury exists. Failure to adhere to established procedures may result in even greater risk. The participant will receive appropriate training from their sponsor on how to identify the hazards and work with materials and equipment safely, and will be supervised in the handling of instrumentation and materials that may pose a risk. I understand that the participant may be removed from the program on a temporary or permanent basis, if he/she refused or is unable to follow the safety rules, wear assigned personal protective equipment and perform the activity as directed.

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 give permission to the Medical University of South Carolina ("MUSC"), its physicians, faculty and staff members, agents and services to provide such emergency care and treatment to the minor, as in their judgment may be deemed necessary or advisable in the event that the minor should require emergency care while participating in the career exploration program at MUSC. I agree to assume the costs of such emergency care and treatment, if any such costs are incurred.

I, the undersigned, for and in consideration of the benefit to be derived by participation in the career exploration program, do herby 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 career exploration program, and do herby further agree to indemnify and hold harmless MUHA, MUSC, their affiliates, agents, servants, representatives and staff, from any and all liability in such regard.

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 employees 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 via email to be cleared for Career Exploration. Requirements will be sent in confirmation email receipt.

By checking "I Agree" below, I agree to these terms and conditions. I hereby certify that the information contained on this form is true and complete. I hereby release the organization, and its employees for any claims or liability, physical injury, or mental anguish sustained by me as a result of my presence in the hospital, or clinical setting. I understand that placement for career exploration is at the discretion of the Medical University Hospital Authority (MUHA).

I Agree