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Job Shadow Program Application Form

Required fields are indicated with (*)

The Lancaster General Health Job Shadow Program is now accepting applications. 

Full Name:*

Are you at least 16 years of age?*

Home Address:*

E-mail Address:*

 Home Phone Number:*

Cell Phone Number:

School Currently Attending:*

Current Grade Level:*

Job Shadowing will be open during the months of February-May and September-November. A person can Shadow in a particular area for two (2) to four (4) hours per year. The date and time provided must be approved by the manager/supervisor of the particular area.

Job shadowing is available Mondays through Fridays, during day shift hours only.

First Choice (no earlier than 3 weeks from date of application)
Date & Time:*

Second Choice (no earlier than 3 weeks from date of application)
Date & Time:*

Please indicate up the area you are interested in shadowing:*

*Restrictions May Apply
Have you previously participated in the Lancaster General Health Job Shadow Program?*

Please read the following statements and check the box with Yes if you agree and No if you disagree. *
My immunizations are up to date and I can provide documentation if requested
I understand that if I have an infectious disease I cannot shadow on that day
Within the past 21 days, I've had chicken pox or I've had the vaccine administered
Allergies: *

Please provide emergency contact information
Name: *

Home Phone Number (or Cell Phone Number):*

Work Phone Number:*

*My typed name below shall constitute an electronic signature and have the same force and effect as my written signature. *

I agree to behave in a responsible and professional manner during my job shadowing experience at Lancaster General Health. I understand that I am only shadowing and will not be permitted to provide any patient care.