CBO Job Shadow Application

Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone Number*

Cell Phone Number*

Personal (not school) E-mail Address*

School Name*

Age*

Grade Level*

What days are you available to participate in the Job Shadow program?*

Select All
Monday, February 17, 8 a.m. - 2 p.m.
Tuesday, February 18, 8 a.m. - 2 p.m.
Wednesday, February 19, 8 a.m. - 2 p.m.
Thursday, February 20, 8 a.m. - 2 p.m.
Friday, February 21, 8 a.m. - 2 p.m.

You must attend orientation (Monday at United Helpers or Tuesday at Community Health Center) and select 1 - 4 additional days.

Please check the departments where you are interested in shadowing.*

Please select no more than 3. Available locations are listed.

Do you have transportation to and from the placement site? (This is a program requirement)*

Please explain why you think you would be a good choice for the Job Shadow Program*

Please explain your future and educational aspirations or goals.*

By typing my name in this field, I certify that the information contained in this application is true and complete to the best of my knowledge.*

PARENT INFORMATION: Please have your parent/guardian complete the following information, acknowledging your interest in participating in this program. PARENT NAME*

Relationship to Applicant*

Phone Number*

E-Mail Address*

Please check each health requirement that you have proof of.*

Select All
Flu shot for this season
Physical within the last year
PPD (TB test) within the last year
2 MMR vaccines

Media Release Confirmation*

Yes
No

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.

Confidentiality Acknowledgement*

I agree

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.

CBO Job Shadow Application Form

Northern New York Area Health Education Center