High School Job Shadow Application

Name*
Preferred First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone Number*
Personal Email Address*
Enter Email Confirm Email

Do not use your school email.
School Name*
Age*
Pronouns
- She/Her/Hers
- He/Him/His
- They/Them/Theirs
- Other
Anticipated Graduation Date*
Birthdate
What season are you 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, times, 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.*
Are you currently employed?*
If yes, where?
Do you have transportation to and from the placement site? (This is a program requirement)*
Do you have previous experience in the healthcare field?*
If yes, please list all previous healthcare experience by identifying the location, date, and nature of the experience.
How did you hear about this program?*
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.*
Please provide a brief description about your involvement in school or community extracurricular activities.*
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*
Email

High School Job Shadow Application

High School Job Shadow Application

Your Regional Partner For Healthcare Workforce Development

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