Lancaster General Health - Lancaster General Health Careers

Full Name:
Are you at least 16 years of age?:
Home Address:
Email:
Home Phone Number:
Cell Phone Number:
School Currently Attending:
Current Grade Level:

Job Shadowing will be open during February – April and September – November. A person can shadow in a particular area one time per year and must be approved by the manager/supervisor of the area. Job shadowing is offered Monday, Tuesday, Thursday or Friday from 8 am – 12 pm, except where noted.

Preferred Date (no earlier than 3 weeks from date of application):

Please indicate up the area you are interested in shadowing:
Have you previously participated in the Lancaster General Health Job Shadow Program:
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:
Are you currently or have you ever been suspended from participation in or subjected to any type of criminal or civil sanction, fine, civil monetary penalty, debarment, or other penalty by any private or public health insurance program, including Medicare, Medicaid, Tricare, or any other federal or state health insurance program?:
Allergies:

Please provide emergency contact information
Name:
Home 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.
Date:
Signature:

Job Shadowing Application