cbo job shadow application

CBO Job Shadow Application Form

    You must attend orientation (Monday at United Helpers or Tuesday at Community Health Center) and select 1 - 4 additional days.
    Please select no more than 3. Available locations are listed.
    I hereby authorize the Northern Area Health Education Center (NAHEC) and hosting facility to photograph, videotape and/or interview or permit others to photograph, videotape and/or interview me or my child. Photos, video clips, and/or interview content of me or my child can be used in media releases (print, radio, internet, or television) or on the NAHEC or hosting facility's website, Facebook page, display boards, brochures, newsletters and other promotional/educational materials in support of the NAHEC mission.
    I understand that in the course of my experience at the camp location, I may learn things of a confidential nature. I agree to keep all information heard directly or indirectly concerning a patient or hospital personnel confidential. I also agree not to disclose information concerning a patient, nor offer patients or family’s advice or opinions. I will respect all patients’ rights.