Sample Survey Page

Name*

Address*

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

Phone Number*

Cell Phone Number*

E-mail Address*

School Name*

Age*

Anticipated Graduation Date*

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*

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Northern New York Area Health Education Center