Observation Application
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
(Required)
Please list the top three areas you would like to observe?
(Required)
Have you been employed by or volunteered at Samaritan before?
(Required)
Yes
No
Please specify when and where you worked:
Please list any volunteer experience(s) you have:
Are you a student?
(Required)
Yes
No
What school do you attend, and what grade level are you in?
Which kind of work do you prefer? Please check all that apply.
(Required)
Patient contact
No patient contact
Clerical
No preference
What is your availability? Please be specific.
(Required)
(Weekends only, Monday-Friday mornings, Tuesday and Thursday evenings, etc.)
Emergency contact:
Contact Name
(Required)
First
Last
Relationship
(Required)
Contact Phone
(Required)
Email
Please submit a copy of your vaccination record, your latest physical exam, and your tuberculosis test (if required by your experience, we can provide the test)
(Required)
Max. file size: 256 MB.
Disclosure Agreement
(Required)
by checking this box, you agree with the disclosure below.
Under the terms of the internship/shadowing opportunities, it is understood that the student/applicant is under the direct supervision of a department manager or designee. Any patient care delivered by the student/applicant (when appropriate) will be under the direction of the department manager or his/her designee and only after student competency has been established and possession of school/personal liability insurance has been confirmed (where applicable). The department manager will secure informed consent from the patient to permit the student to participate appropriately in the provision of patient care. Department managers or designees will accept responsibility for the supervising and directing of students who wish to serve internships/shadowing opportunities with them at Samaritan.
By checking this box, the student/applicant understands and accepts the educational experience as described above. The student agrees to abide by the rules and regulations of Samaritan.
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