| Full Name:* |
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| Are you at least 16 years of age?* |
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| Home Address:* |
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| E-mail Address:* |
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| Home Phone Number:* |
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| Cell Phone Number: |
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| School Currently Attending:* |
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| Current Grade Level:* |
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Job Shadowing will be open during the months of February-May and September-November. A person can Shadow in a particular area for two (2) to four (4) hours per year. The date and time provided must be approved by the manager/supervisor of the particular area.
Job shadowing is available Mondays through Fridays, during day shift hours only.
First Choice (we will notify you within 2 weeks regarding confirmation of your request)
Date & Time:* |
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Second Choice
Date & Time:* |
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| Please indicate up to two (2) areas you are interested in shadowing:* |
*Restrictions May Apply
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| Have you previously participated in the Lancaster General Health Job Shadow Program?* |
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| Please explain your goal for your requested job shadowing experience to assist us in providing the most beneficial opportunity for you.: * |
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| Please read the following statements and check the box next to the statement if you agree. * |
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| Allergies: * |
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Please provide emergency contact information
Name: * |
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| Home Phone Number (or Cell Phone Number):* |
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| Work Phone Number:* |
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*My typed name below shall constitute an electronic signature and have the same force and effect as my written signature. *
I agree to behave in a responsible and professional manner during my job shadowing experience at Lancaster General Health. I understand that I am only shadowing and will not be permitted to provide any patient care. |
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| Date* |
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