Job Shadowing

Mississippi County Hospital System

Job Shadowing Application

Please complete the following.

Full Name

First and Last Name

Middle Initial

Current Address

Home Phone

Cell Phone

Email Address

Current Age

Date of Birth

Last four social security numbers

Current School

School and Program Applying to:

Department(s) you wish to shadow in order of preference

Your Availability to Shadow

Complete applications will be processed in the order they are received. It may take up to two weeks for your application to be processed.

Please list your first, second, and third-choice dates and times based on your job, school schedule, etc. Also state what time/day is best for you if your first three specific dates are not available. For example, if you want to shadow on Monday the 10th of the month, but you are available any Monday, any shift, please write "any Monday, any shift" in the right-hand column.

1st choice date:

Day of Week/Time

2nd choice date

Day of Week/Time

3rd choice date:

Day of Week/Time

You will be notified of the date, time, and place you are scheduled to shadow through the e-mail address you have written above. Please make sure it is legible. Only complete applications will be processed.

Emergency Contacts
In case of medical emergency, Mid-MO AHEC must be able to reach a relative or other emergency contact.

Primary Contact:

Name

Relationship:

Address:

Primary Phone

Other Phone

Secondary Contact:

Name

Relationship:

Address to Student:

Primary Phone:

Other Phone:

Release of Liability

I hereby agree that while I am participating in any MCHS educational experience, Mississippi County Hospital System will not be held responsible for any injury or accident that might occur. Any medical expenses incurred as a result of such injury or accident will be my responsibility.

Participants Signature

Date

Medical Release

(For participants under age 18) I understand that in case of a medical emergency, every attempt will be made to contact me before medical action is taken. However, this document is my consent as a parent or guardian of the participant for emergency treatment or procedure necessary by the professional staff of the closest hospital available. I understand that as a Job Shadow student the Mississippi County Hospital System does not provide him/her with accident or medical insurance, and is therefore not responsible for any accident or medical expenses incurred by him/her and me. Further, I understand that he/she is neither covered by Worker's Compensation nor entitled to employee benefits as a result of his/her job shadow affiliation.

Parent/Guardian Signature

Date

Insurance Company

Policy Number