/ Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org

Crossroads Clinical Application

When you submit this application, please rename the file LastName_FirstName_SHOWClinicalApp AND submit only as a PDF

Applicant Information

Full Name: /
Date:

Last

/

First

/

Middle

Address:

Street Address

/

Apartment/Unit #

City

/

State

/

ZIP Code

Phone #: /
Email:
University Affiliation: /
Major:
Expected Graduation Date:
Can you speak Spanish? / FLUENT / MODERATE / NO
Have you worked for SHOW in the past? / YES / NO /
If yes, when?
If yes, please explain:

Emergency Information

Emergency
Contact: /
Relationship:
Phone #:

Long Response

*** Please also include a copy of your resume upon application submission ***

Why do you want to participate in SHOW through Crossroads, and what do you hope gain as a volunteer? (200 word max.)

Roles and Responsibilities

●Undergraduate Clinical Navigator (for undergraduate/graduate students): Responsible for escorting patient throughout the clinic, maintaining an efficient patient flow, informing patient of special events and resources, and working with the clinical team to ensure quality improvement.

●Health Professional Student Volunteers (for graduate students): Composed of various health professional students responsible for assessment, formulating diagnoses, treatment planning, and evaluation of primary care patient problems.

Volunteer Requirements

Volunteer Requirements are based on your role within SHOW. Please note that Student Clinical Volunteers include any student who will be working with patients/clients. Student volunteers must be a student of ASU, NAU or U of A.

Once you have submitted your application and it has been reviewed you will be asked to submit documentation of the requirements list below and may be asked to complete additional forms. Please begin to gather this information in preparation.

Committee / Faculty Mentor / Research Committee / Student Clinical Volunteer / Front Desk / Clinic Preceptor/Provider
Required
Volunteer Application / x / x / x / x / x
CITI Training
Update every 4 years / x / x / Faculty: Required
Community: Not Required
CV/Resume – every 2 years / x / x
TB Skin Test
Every 2 Years / x / x / x
Vaccination: MMR Series
(or proof of immunity) / x / x / x
Vaccination: Hepatitis B Series
(or proof of immunity)
Waiver available upon request / x / x
BLS/CPR
Every 2 years / x / x
HIPAA Training
Annually / x / x / x / x
Blood Borne Pathogen
Annually / x / x / x
Board Certification
(if applicable) / x
DEA License (if applicable) / x
AZ State License / x
Attend Orientation Class / x / x / x / x / x
Credentialing Paperwork / MD/NP/PA providers only
Recommended / Preferred
Vaccination: Influenza annually / x / x / x / x
Vaccine: Hepatitis A Series / x / x / x
Vaccine; Tdap (Tetanus, Diphtheria and Pertussis) or Td / x / x / x / x
ACLS
Update every 2 years / x
Dispensing Privileges (if applicable) / x