College job shadow application

Name*
Address*
Cell Phone Number*
E-Mail Address*
School Name*
Major*
Anticipated Graduation Date*
Birthdate*
Age*
Which season would you be available to participate in the Job Shadow Program?*
- Spring
- Summer
- Fall
You may choose more than one, but please take into consideration your involvement with extracurricular activities.
Please provide specific availability for shadowing (school breaks, days, time, etc.)*
What healthcare fields are you interested in? Please list your top three preferences.*
Do you have a specific placement site in mind? Please list your top three preferences.*
In 250 words or less, please let us know why you should be included in the Post-Secondary Shadow Program
Please describe all previous healthcare experience by identifying the location, date and nature of the experience.*
Please explain your future short and long-term education and career goals.*
I am a matriculated student of a health training program or health related major.*
- Yes
- No
I am in good academic standing.
- Yes
- No
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.*