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Job Shadowing / Clinical Experience Opportunity Request
Providence Medical Center: 1200 Providence Rd Wayne, NE 68787
First and Last Name
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Phone Number
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Email Address
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Date of Birth
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Year
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Name of School
Year in School
Are you under the age of 19?
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Yes
No
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* Complete this Section if Under 19 Years of Age
Parent or Guardian
First and Last Name
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Relationship
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Phone Number
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Department/Occupational Background
Occupation/Department you would like to shadow
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Name of Person you would like to shadow, if known
Briefly describe your reason for wanting to job shadow, including learning and career objectives, number of hours you want to shadow, observational requirements, etc.
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What date(s) and time(s) you are available for your job shadow?
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Emergency Contact Name, Relationship, and Phone Number
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Do you have any limitations or special needs which need accommodation? If yes, please explain.
Have you ever volunteered or been employed by Providence Medical Center? If yes, when?
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Vaccination Record
Please indicate all vaccinations you have received:
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Tdap (tetanus/diphtheria/pertussis)
HPV (Human Papilloma Virus) Vaccine
MCV4 (Meningococcal Conjugate Vaccine)
Pneumococcal Vaccine
HepB (Hepatitis B Vaccine Series)
IPV (Inactivated Polio Vaccine)
MMR (Measles, Mumps, Rubella Vaccine Series)
Varicella Vaccine Series (Chicken Pox)
Influenza
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Verification of Accurate Information
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Signature
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