ClinicalStudent - by System32, Inc.

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Job Shadow Application
Note: All questions are required unless noted, optional. Note: Phone number provided may be used for contact via text or phone call.

Legal Name *

Address *

Emergency Contact *

Pre Screening Questions: Check the box if Yes.

Interest: Please indicate the nature of your shadowing request. (If selecting ‘Other,’ please add your reason in the space provided).

Career Exploration
College/University Program/Course Requirement
Clinical Observation Hours (non-licensed observer)
Pre-Employment Exploration
Other

Select the Location(s) you are interested in job shadowing

List dates & shifts you are requesting job shadow

Mon
Tue
Wed
Thu
Fri

Sat
Sun

Type of CoxHealth Employee you are seeking to shadow (check all that apply)

Emergency Medical Services (Paramedic/EMT)
Medical Laboratory Scientist / Lab Technician
Occupational Therapist
Pharmacist/Technician
Physical Therapist
Physician (MD/DO)
Radiologic Technologist / Imaging (X-ray, CT, MRI)
Registered Nurse (RN)
Respiratory Therapist
Surgical Technologist (Operating Room)
Other

Sponsor

Terms & Conditions

Job shadowing participants understand that participation in the shadowing program may be hazardous, and CoxHealth and its officers, directors, employees, affiliates, subsidiaries, successors, and representatives are not responsible for the consequence of any such hazards. Shadowing program participants understand and agree that CoxHealth is not responsible for and assumes no liability for risks or dangers encountered by participants in the shadowing program, or for any accidents, injuries, or illnesses that may occur as a result of participation in the shadowing program.

Participants assume any and all risks, agree that CoxHealth shall not be liable for any loss or damage relating to such risk, and agree to hold CoxHealth, CoxHealth Job Shadowing Program participants and authorized representatives harmless for any claim resulting for any such losses or damages. I agree and covenant not to sue CoxHealth and its authorized representatives relating to or resulting from such risks. Services of CoxHealth: CoxHealth only provides an environment which exposes participants of the job shadowing program to a variety of experiences encountered in the day-to-day risks of the healthcare disciplines of interest to program participants. The authorized representatives of CoxHealth and the job shadowing representatives have no control over risks or dangers associated with participation in the program and are not responsible for any injury, illness, damage, or loss which may be occasioned through participation in the job shadowing program. Participation representations: Each job shadowing program participant represents that he or she has reached the age of majority, has read and understood the terms and provisions of the job shadowing program, and agrees to be bound thereby as a condition to participating in the job shadowing program.

The parent or legal guardian of a job shadowing program participant who has not reached the age of majority agrees that both the minor and the legal guardian agrees to indemnify and hold CoxHealth, CoxHealth Job Shadowing Program participants, and authorized representatives harmless from any claim by the minor resulting from any loss or injury.