JOB SHADOW REQUEST FORM
St. Croix Regional Medical Job Shadow opportunities are open to individuals 14 years of
age and older with the exception of the Operating Room, where individuals need to be 16 year of
age or older. (Individuals under the age of 14 are afforded an opportunity to take part in a
structured facility tour rather than a job shadow experience).
Job shadow participants will adhere to the following stipulations in the course of the job
shadowing experience at St. Croix Regional Medical Center.
In requesting this job shadow experience, I agree to:
1. Follow all directives of the personnel to whom I am assigned.
2. Will not interfere with the care/treatment of any patient nor disrupt any
department’s scheduled activities.
3. Will remain in the designated department during all job shadowing periods unless
excused by the supervisory/assigned personnel.
4. Will keep all patient information completely confidential.
5. Will not provide patient care/treatment.
I specifically desire to see the following area(s)/department(s) ________________________ so
that I may gain the most observation/experience. In addition I agree to hold St. Croix Regional
Medical Center and its employee harmless and indemnify/release St. Croix Regional Medical
Center from any and all claims that may arise out of, or in any way, be connected with my
observational experience.
Below are the dates/times that work best for me.
st
1
preference (list date/time) _________________________________________________
nd
2
preference (list date/time) _________________________________________________
rd
3
preference (list date/time) _________________________________________________
Students Name: ____________________________________
Age: ______________
Address: _________________________________________________________________
Phone Number: ______________________ Email address: ________________________
Students Signature: _________________________________
Date: _____________
Parent’s Signature (if student is under 18 years of age): ___________________________