Job Shadow Request Form printable pdf download

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.

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): ___________________________

Job Shadow Request Form