Job Shadow Application for Adults

  
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Last Name:
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First Name:
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Street Address:
Apartment:
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City:
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State:
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Zip Code:
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Phone Number:

Format: (xxx) xxx-xxxx

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Email Address:
Location Requested:


Additional Information

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Highest level of education completed:
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Name of School:
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Career Interest:
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Have you volunteered at Sparrow within the last 12 months?

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Please write a sentence or two as to why you would like to job shadow:
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I am interested in the Job Shadow Program because:



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Are you a Sparrow employee?:

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Have you ever been terminated from Sparrow Health System?

Emergency Contact Informaton

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Last Name:
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First Name:
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Street Address:
Apartment:
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City:
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State:
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Zip Code:
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Phone Number:

Format: (xxx) xxx-xxxx

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Relationship:

I have read and agree to the following:

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1. I will attend the required orientation with Human Resources and will complete the orientation within 1 year of orientation (TB skin test expires after 12 months). Orientation for Sparrow Clinton and Sparrow Ionia sites will be scheduled by HR following receipt of your application.

2. I will uphold all Sparrow Health System's policies, procedures, and protocols.
 
3.  I expect no remuneration for this education experience.
 
4.  I will participate ONLY as an observer and, will NOT participate in any hands-on activities involving the patient.

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Name:
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Date:

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