Please complete this application form if you are interested in the Rehab Shadowing experience at Ascension Sacred Heart. Once you complete the form, click the Continue button at the bottom.


Eligibility:

Students 18 years of age and older who are undergraduates or seeking enrollment in a college or university with an interest in a possible healthcare career path.



Contact Information:


Have you received your COVID Vaccine?

The COVID vaccine is a requirement, if you do not wish to receive the vaccine you are ineligible to volunteer at this time.



Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.



School Requirement - Verification

Are you needing hours to fulfill a school requirement? 

If you are a college student already in a healthcare (accredited) program please contact Student Onboarding at: student.onboarding@shhpens.org

All others please answer below:



Emergency Contact

In the event of an emergency whom should we notify?




Criminal Background History & Consent

Have you ever been convicted of a crime and/or are there any legal charges pending against you?



Affirmation Statements

I agree to abide by all of Ascension Sacred Heart Health System policies and procedures which include the dress and appearance policy for observers. I agree that as I participate in the Career Shadowing/Observation program my role will be as an observer only and I will not be permitted to provide direct patient care or participate in any patient procedure.

At all times, I must be under the supervision of the sponsor. In addition, I understand that patients may exercise their rights to not participate in the Rehab Shadowing program.

I understand that in the course of my Rehab Shadowing program experience I may come into contact with confidential patient information. I will not at any time during or after my experience at Ascension Sacred Heart Health System disclose any patient information to any person or use patient information, other than necessary.

I understand that participation in this program is voluntary and without compensation and that Ascension Sacred Heart Health System is not responsible for any expenses incurred during, or as a result of, my participation in the Rehab Shadowing program.

In consideration for participation in the Rehab Shadowing program  I hereby waive, discharge and agree to hold harmless Ascension Sacred Heart Hospital, it's agents and employees from any and all liability, claims, demands, and actions arising out of or relating to any loss, liability, damage or injury sustained by me, or any property belonging to me while participating in the program.



Criminal Background History Consent & Statement

I hereby give my consent to conduct a criminal background history through the local county clerk of court records.
I understand that this information will be used to determine my eligibility for job shadowing at Ascension Sacred Heart Hospital.
I waive and release Ascension Sacred Heart and its agents from any and all claims I may otherwise have with respect to any such criminal background check.