Job Shadow Application
Application for South Central Public Health District
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Email *
Full Name
Address
Phone number
School you are currently attending
Name and email of teacher requiring this job shadow
When are you available to complete the job shadow hours? *Note: South Central Public Health District's office hours are Monday through Friday, 8 A.M. to 5 P.M.
Areas of special concern or interest
Do you understand and agree to the following? 1. Any patient or client of South Central Public Health District has the right to complete confidentiality. Client clinical services and medical records are subject to HIPAA policies. All volunteers, students and interns must comply with Federal, State, and District HIPAA policies. 2. If asked to perform a function that required the use of an automobile, you will ride with a district employee in a district car, and will follow the established policies. Reimbursement for driving a personal vehicle is not allowed. Non-district employees are not allowed to drive district vehicles. 3. You will claim no salary compensation for your services for South Central Public Health District. Any services you perform will be strictly on a volunteer basis.
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I affirm that this application contains no misrepresentation or falsification and that the information is true and complete. I understand I may be required to undergo/pass a background check and drug screen and will be given more information on cost/instruction upon acceptance of this application.
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A health district employee will be in contact with you within 2 business days after you submit your application. Thank you for your interest in interning with South Central Public Health District.
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