Superior Commitment. Exceptional Care. Always.
Medical Services
select
Online Services
select
Job Shadow Day Request

*
Name
*
Email
*
Telephone
*
Address1
Address2
*
City
*
State
select
*
Zip
  
Have you been exposed to any of the illnesses listed below, within the past 2 to 3 weeks?

Check all that apply.







Are you experiencing any of the following symptoms?

Check all that apply.








*
Are you over 18 years of age?
*
Birthdate

01/01/2011

*
School or College and Major
*
Career Goals
*
What do you hope to gain by shadowing at Carroll Hospital Center?
*
Print Signature
*
Today's Date

01/01/2011

Parent/Guardian signature is required if the Shadow participant is less than 18 years old.

Parent/Guardian Signature
Today's Date

01/01/2011

In case of emergency please contact:

*
Name
*
Relationship
*
Home Phone
*
Work/Cell Phone

By signing below, I agree to the following:

*
    1. The Shadow Day is OBSERVATION ONLY with no "hands-on" experience.
    2. There is potential for exposure to bloor and/or body fluids in the hospital setting.
    3. For everyone's protection, Carroll Hospital Center reserves the right to cancel your participation in the Shadow Day program in the event of illness or exposure to a contagious disease within the last 2 to 3 weeks.

Agree: