If you are a college student or exploring a career change and are over 18, or a high school student interested in nursing, please complete this Shadowing Application to be considered. Once you complete the form, click the Continue button at the bottom.


Contact Information


Demographic Information


Days & Times Desired to Shadow

Shadowing ranges from 1 to 5 days in 4-8 hour blocks. Please indicate the days and times you would be available for shadowing.  See:  Shadowing Policy



Email Preferences

We like to keep you informed of important news, schedules, and changes by email, however will not send you any email you prefer not to receive. Use the checkboxes below to select the kinds of email you would like to receive from us.



Career Shadow

Please tell us what your major is and where and with whom you desire to shadow. Shadowing physicians or advanced clinical providers is not permitted.



Emergency Contact Information


Employer


References


Seasonal Address

If you have a different address during school you would like us to have, please feel free to share it here.



Health Requirements

If you were born after 1957, please contact your family physician to get this information. If there are any vaccinations you need, you will need to get them prior to beginning as a Volunteer. You will need to bring a copy of this verification when you come for your interview.

1. Have you had TWO Measles, Mumps, Rubella (MMR) Vaccinations? If not, have you had a documented case of the Measles or the German Measles? If not, you will need to contact your physician for a Rubeola titer.

2. Have you had chickenpox? If not or unsure, you will need to contact your physician for a Varicella titer.

3. Have you had a negative PPD (Tuberculosis) skin test within the last 12 months? If YES, please provide a copy of the negative result. If not or you are unsure, you will need to contact your physician for a PPD skin test.

4. Between October 1 & April 30, have you received your seasonal flu shot? If YES, we will need a copy of the verification of when you received it. If not, you will need to contact your physician to receive it at least 2 weeks prior to your shadowing experience.

5. Have you received a TDAP vaccine? If YES, we will need a copy of the verification when you received it. If you have not had one, you will need to contact your physician to receive it if you plan to shadow with children or infants.

6.  Have you received your COVID-19 Vaccination? If YES, we will need a copy of the vaccination card. If NO, you will not be permitted to shadow.



Criminal History

You will be required to have a criminal background investigation before being accepted to Shadow. If you have ever committed, been convicted of, pled guilty to, or pled nolo contendo to, a felony or a misdemeanor, please explain here. If not disclosed & is reported through the background check, you will not be accepted into the Shadowing program.



I Agree

     I understand and agree that submitting this application form does not automatically guarantee me a position to Shadow with United Hospital Center, and that there may be certain qualifications I must meet, including the acceptance of established policies and procedures before I may begin shadowing.

     I hereby allow the Auxiliary to United Hospital Center, to perform a check of my background & references. I understand that I do not have to agree to this background check, but that refusal to do so will exclude me from consideration.

     I hereby also give my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability for shadowing at UHC and other information they deem appropriate.

     I hereby give my permission to take, reproduce & use my photograph, name, quotations or comments in connection with any publication (including but not limited to newspapers, TV, video, radio, brochures & magazines) in such manner & at such times as United Hospital Center and/or the Auxiliary to United Hospital Center shall determine.

     By submitting this form, I further certify that all my answers and statements are true and complete and understand that falsification of information on this application is reason to exclude me from consideration.