Applicant Information First Middle Last Applicant Contact Information E-Mail Phone Are you at least 18 years old? Yes No How old are you? - Select -1617 If you are under 18 years of age, a parent or legal guardian must sign this application application. Emergency Contact Name Emergency Contact Phone Are you currently employed at Froedtert ThedaCare Health, Inc. South Region? Yes No Department Role Are you currently a medical student at the Medical College of Wisconsin? Yes No Are you a volunteer at Froedtert ThedaCare Health, Inc. South Region? Yes No Identify purpose and objectives for this job shadow experience. Is job shadow experience required for school? Yes No School Name Program Type/Name Grade Level Choose the facility location where you would like to job shadow. Froedtert Hospital Froedtert Menomonee Falls Hospital Froedtert West Bend Hospital Froedtert Holy Family Memorial Hospital Froedtert Community Hospital (Mequon, New Berlin, Oak Creek, Pewaukee) Froedtert & MCW Health Center or Clinic Choose all that apply. Froedtert Community Hospital Location Mequon New Berlin Oak Creek Pewaukee Choose all that apply. Froedtert & MCW Health Center or Clinic Location Choose a role or occupation to shadow. - Select -Physician/Medical Doctor (MD)*Physician Assistant*Nurse Practitioner*Certifiied Registered Nurse Anesthetist (CRNA)*Certified Anesthesiologist Assistant (CAA)*Registered NurseAudiologyBiomedical EngineeringCardiovascular TechCertified Nursing Assistant (CNA)ChaplainDietitianDietetic TechnicianDosimetryEchocardiologyEmergency Medical Tecnhician (EMT)Exercise Physiology/KinesiologyHealth Information Management (HIM)Health Unit Coordinator (HUC)Information Technology (IT)Medical Assistant (MA)Medical Interpreter/Language ServicesNeurodiagnosticNuclear MedicineOccupational TherapyPathologyPerfusionPharmacyPharmacy TechnicianPhlebotomyPhysical TherapyRadiography (Imaging)Radiology TechnicianRespiratory Therapy (RT)Social WorkSonography (Ultrasound)Speech TherapySpeech Language PathologySterile ProcessingSurgical TechnicianWisconsin Diagnostic Laboratories Roles with an asterisk require a pre-arrangement. We do not contact professionals in these roles/occupations. You will need to enter the name and role of the professional you have an arrangement with below. Registered Nurse Role - Select -Critical CareMed/SurgOncologyProgressive Care You selected a role that requires pre-arrangement. We do not contact professionals in these roles/occupations. Please enter the name and role of the professional with whom you have set up your job shadow/observation. If you have already arranged for a job shadow experience with a team member, please provide the team member's name and role. Pre-Arrangement Team Member Pre-Arrangement Team Member Role/Department Number of Hours You are not allowed more than 4 hours unless agreed upon with the job shadow coordinator. Agreements I attest that I, the undersigned individual applying for a Job Shadow Experience, agree to the following items.Please check the box to agree to the statements. All are required. Confidentiality The Job Shadow participant agrees that all nonpublic information, including patient information and information related to the health care organization’s business, intellectual property and materials acquired or received during the course of the Job Shadow participant are treated as confidential and will not, unless required by law or otherwise specifically permitted by the health care organization, be disclosed or used during or after the Job Shadow participant’s Job Shadow Experience unless the information: (i) is or becomes publicly available through no fault of the Job Shadow participant, (ii) is disclosed to the Job Shadow participant by a third party not subject to any obligation of confidence, (iii) is independently developed by the Job Shadow participant without the use of confidential information, or (iv) is already known or possessed by the Job Shadow participant prior to disclosure. Release/Indemnification Job Shadow participant agrees to release and hold harmless the Organization, its members, directors, officers, team members and representatives from any liability for injuries, losses, damages or expenses arising from the Job Shadow participant's own conduct during the Job Shadow Experience at the Organization. The Job Shadow participant will defend and indemnify the Organization, its members, directors, officers, team members and representatives for all claims, losses, damages, cost and other liabilities (including attorney’s fees) resulting in any way from the acts or omissions of the Job Shadow Experience, except to the extent that such claims arise out of the negligence or willful misconduct of the Organization, its members, directors, officers, team members and representatives. Organization Policies The Job Shadow participant agrees to conform to all policies and procedures, including those relating to safety, patient care and nondiscrimination. These policies and procedures include all standards covered by (including but not limited to) the Organization’s Code of Conduct, Joint Commission and Occupational Safety and Health Administration requirements. Medical Conditions To avoid exposure of risk to any of the Organization’s patients or team members, Job Shadow participants must be free from any symptoms of communicable disease, including but not limited to: fever 100.4 or greater, new onset cough/runny nose, sore throat, body aches/chills, severe nausea, vomiting, diarrhea. Job Shadow participants will be required to wear a mask if they have any mild respiratory symptoms, even if they have a known medical condition. Medical Treatment The Job Shadow participant agrees the Organization shall provide or refer the Job Shadow participant for outpatient treatment in the case of an accident or illness while in the Organization’s facilities. Illness The Job Shadow participant hereby forever releases and shall discharge all claims and causes of action whatsoever, present and future, against the Organization, its members, directors, officers, team members and representatives, related to or arising out of any illness, disease or health condition the Job Shadow participant may contract, develop or come into contact with while on the premises of the Organization, except those that arise from any negligent act, omission or willful misconduct of the Organization, its members, directors, officers, team members or representatives. I have read, understand and agree to abide by all terms and conditions outlined in this Agreement as a condition of participating in a Job Shadow Experience at Froedtert ThedaCare Health, Inc. South Region. Applicant Signature Reset Sign above Please type your name Parent or Guardian Signature Reset Sign above Parent or Guardian Name Relationship to Applicant Submit For Professionals Professional Education Administrative Fellowship Program Diagnostic Medical Sonography Program Finance Fellowship Program Graduate and Doctorate Nursing Students Placements Interventional Radiology Internship Job Shadow Experience Job Shadow Experience Application Non-Nursing Student Placements Nuclear Medicine Technology Program Nursing Residency Nursing Student Undergraduate Placements Pharmacy Residency School of Radiologic Technology Physical Therapy Residency