Lancaster General Health - Job Shadowing Program Application

Full Name:
Are you at least 16 years of age?:
Home Address:
Email:
Home Phone Number:
Cell Phone Number:
School Currently Attending:
Current Grade Level:

Job Shadowing will be open during February – May and September – November. A person can shadow in a particular area one time per year and must be approved by the manager/supervisor of the area. Job shadowing is offered Monday, Tuesday, Thursday or Friday from 8 am – 12 pm, except where noted.

Preferred Date (no earlier than 3 weeks from date of application):

Please indicate up the area you are interested in shadowing:
Have you previously participated in the Lancaster General Health Job Shadow Program:
My Immunizations are up to date and I can provide documentation if requested:
I understand that if I have an infectious disease I cannot shadow on that day:
Within the past 21 days, I’ve had Chicken Pox or I’ve had the vaccine administered:
Allergies:

Please provide emergency contact information
Name:
Home Phone Number:
Work Phone Number:

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.
Date:
Signature: