Name
*
First Name
Last Name
Email
*
Date of Birth
*
MM
DD
YYYY
Phone Number
*
(###)
###
####
Emergency Contact
*
First Name
Last Name
*
Phone Number of Emergency Contact
(###)
###
####
Grade (High School)
*
Freshman
Sophomore
Junior
Senior
GPA (Most Recent, Weighted)
*
How did you hear about us?
*
Instagram
HOSA
School Event
Other
Why are you interested in shadowing a physician?
*
What are you currently involved in, both in and out of school?
*
Do you have a specific field of medicine that you are interested in? If so, why?
*
Do you have any medical experience? (Volunteering, shadowing, research)
*It is okay if you do not*
When is your next day off from school?
*
*We will pick your shadow date based off of your selection*
MM
DD
YYYY
List following days off as well:
Which physician/clinic would you most like to shadow?
*
*Pick One*
Do you have any questions or concerns?
Participation Agreement
*
By enrolling in the MedPathNE shadowing program, you understand and accept the possible risks associated with observing clinical environments. You understand and agree to waive any claims against MedPathNE, its staff, partners, or affiliates for damages, injuries, or losses that may occur during the course of the program, as your participation is voluntary.
As a participant of the program, you are expected to follow all protocols, policies, and professional standards set by the hosting clinic or physician. You must remember that you are within their jurisdiction and under their rules, so you must follow them. This includes strict adherence to patient confidentiality and safety procedures, which are set by the national policies of HIPAA. Failure to comply with these expectations may result in immediate removal from the program. MedPathNE will not be held liable for any consequences resulting from the violation of rules or misconduct.
Please note that MedPathNE does not offer health or liability insurance coverage for participants of the program. Securing any necessary insurance before engaging in shadowing activities is your responsibility. MedPathNE holds the right to discontinue your participation at any time.
To take part in this program, the presented terms and conditions must be adhered to, as well as acceptance of any updates.
