Address Line 2
District of Columbia
Northern Mariana Islands
U.S. Virgin Islands
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Birth
MM slash DD slash YYYY
Please list the top three areas you would like to observe?
Have you been employed by or volunteered at Samaritan before?
Please specify when and where you worked:
Please list any volunteer experience(s) you have:
Are you a student?
What school do you attend, and what grade level are you in?
Which kind of work do you prefer? Please check all that apply.
No patient contact
What is your availability? Please be specific.
(Weekends only, Monday-Friday mornings, Tuesday and Thursday evenings, etc.)
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)
Max. file size: 256 MB.
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.