Greater Green Bay Healthcare Alliance

Greater Green Bay Healthcare Alliance

ADULT JOB SHADOW APPLICATION

APPLICANT INFORMATION
First Name: Click here to enter text. / Last Name: Enter text. / Sex: ☐ Male ☐ Female
Street Address:Enter text. / City: Enter text. / State: Enter text.
Zip: Enter text. / Home Phone w’ Area Code: Enter text.
Cell Phone w’ Area Code: Enter text. / Email Address: Enter text.
Do you have a diploma or GED? ☐Yes ☐ No / Number of years of post-high school education:☐1 ☐2 ☐ 3 ☐4 ☐5+
Do you have a post-secondary degree? ☐Yes ☐ No / If yes, please list: Enter text.
Today’s Date: Enter a date.
REFERRAL INFORMATION
Referral Facility: Enter text.
SHADOW REQUEST INFORMATION
Please list the job title you wish to shadow. Be as specific as possible: Enter text.
Briefly describe your career goals (what you hope to go to college for, specialize in, etc.): Enter text.
Is there a specific facility you would prefer to shadow at? ☐Yes ☐ NoIf yes, please list: Enter text.
Please check the days and times you are available for a tour. Check all that apply. *Note: Your job shadow may range between one to four hours in length.
MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY
☐ 8:00 -10:00 am / ☐ 8:00 -10:00 am / ☐ 8:00 -10:00 am / ☐ 8:00 -10:00 am / ☐ 8:00 -10:00 am
☐ 10:00 am–12:00 pm / ☐10:00 am–12:00 pm / ☐10:00 am–12:00 pm / ☐10:00 am–12:00 pm / ☐ 10:00 am–12:00 pm
☐ 12:00 – 2:00 pm / ☐ 12:00 – 2:00 pm / ☐ 12:00 – 2:00 pm / ☐ 12:00 – 2:00 pm / ☐ 12:00 – 2:00 pm
☐ 2:00 – 4 pm / ☐ 2:00 – 4 pm / ☐ 2:00 – 4 pm / ☐ 2:00 – 4 pm / ☐ 2:00 – 4 pm
☐ 4:00 – 6:00 pm / ☐ 4:00 – 6:00 pm / ☐ 4:00 – 6:00 pm / ☐ 4:00 – 6:00 pm / ☐ 4:00 – 6:00 pm
☐ 5:00 – 7:00 pm / ☐ 5:00 – 7:00 pm / ☐ 5:00 – 7:00 pm / ☐ 5:00 – 7:00 pm / ☐ 5:00 – 7:00 pm
CONFIDENTIALITY AGREEMENT
Applicant agreement: I agree to use proper language and maintain a respectful manner at all times. I will seek out and follow directions of my assigned mentor/sponsor, especially in any code or emergency situation. I understand confidentiality is of the utmost importance, and will keep all confidential information confidential. I will abide by the appearance guidelines and wear any ID badges provided to me. I understand this job shadow experience may be cancelled at any time due to business needs. The Greater Green Bay Healthcare Alliance nor its members shall be responsible for adverse occurrences and/or outcomes. I assume full responsibility for any treatment deemed necessary. The electronic submission of your application indicates your agreement to the above statements. Please initial below to formalize your agreement.
Applicant’s Initials: Enter text. / Date: Enter a date.
IN CASE OF EMERGENCY
Name of emergency contact available during the shadow experience: Enter text.
Relationship: Enter text. / Home Phone w’ Area Code: Enter text.
Work Phone w’ Area Code: Enter text. / Cell Phone w’ Area Code: Enter text.

Applicant: Please save a copy of the completed application form for your records.

FOR FACILITY USE ONLY – Click each box to electronically enter text or the date.
Application
Received / Department
Contacted / Shadow Mentor Assigned / Job Shadow
Date / Job Shadow
Time / Job Shadow Location / Confirmation
Sent / Facility/Mentor
Phone Number

Adult Job Shadow Application 6/9/2017