Kate Ford | Volunteer and Student Experiences |15 Hospital Drive, York, Maine 03909 | [email protected] | 207-351-2224 fax: 207-351-2489
JOB SHADOW APPLICATION
JOB SHADOW DATE (s): _______________________
Personal Information:
Date: _________________________
Name: __________________________________________Preferred First Name for Name Badge: __________
Last First
Mailing Address: ___________________________________________________________________________
Street or P.O. Box City State Zip
Home Phone: ___________________________________ Cell Phone: ________________________________
E-Mail: _______________________________________ Date of Birth: ______________________________
School Attending: _______________________________ School Phone: _____________________________
Emergency Contact: _____________________________ Phone: ___________________________________
Job Shadow Information:
Occupation you’re interested in job shadowing: ___________________________________________________
Please include the name of someone you would like to job shadow (optional): ___________________________
Have you job shadowed here before? If so, when and with whom?____________________________________
Arrival Time: ______________________________Departure Time: __________________________________
Please note: we will do our best to accommodate a time that works best for you. However, we will be in touch
with you if we are unable to accommodate the requested time.
Do you have any special concerns or requests: ____________________________________________________
__________________________________________________________________________________________
Confidentiality Agreement:
I understand that it is the policy of York Hospital to ensure that the business operations, activities and personal
information of York Hospital, its patients, and employees are kept confidential to the greatest possible extent. If,
during the course of my time at York Hospital, I acquire confidential or proprietary information about York
Hospital, or its patients and employees, I will handle such information in strict confidence and not discuss it
with outsiders or with co-workers beyond what shared knowledge is needed to carry out the business operations
and clinical services of the hospital.
By signing below I agree to York Hospital’s Confidentiality Agreement
__________________________________________ __________________________________________
Job Shadow Applicant Signature Date
If under 18, please fill out the parental/guardian consent below and submit with job shadow application.
Please return completed form(s) to:
1. Have you had the COVID Vaccine? YES NO
If yes, please submit COVID vaccine information with paperwork including booster shot information.
2. Please submit flu documentation with date and lot# during flu season (between Oct 1-Mar 31).
Kate Ford | Volunteer and Student Experiences |15 Hospital Drive, York, Maine 03909 | [email protected] | 207-351-2224 fax: 207-351-2489
DRESS CODE
DRESS CODE
As a job shadow candidate you are not only representing yourself but you are now representing York Hospital.
Our physical appearance gives patients and visitors an impression about York Hospital and the quality of care
that we provide. Being a representative of York Hospital, we ask that all job shadow candidates dress neatly and
professionally while maintaining personal grooming and cleanliness.
To help patients, visitors, and other staff members, we ask that all job shadow candidates follow the dress code
unless instructed otherwise.
Wear a name badge indicating who they are during the job shadow in the hospital or other path areas.
Do not wear jeans, gym shorts, cotton shorts, short shorts, or short skirts.
Do not wear rubber or plastic flip flops. Sneakers are the recommended footwear.
Do not wear clothes that are too tight or too low.
Do not wear any perfume or cologne.
Thank you for honoring York Hospital’s dress code policy.
Kate Ford | Volunteer and Student Experiences |15 Hospital Drive, York, Maine 03909 | [email protected] | 207-351-2224 fax: 207-351-2489
PARENTAL / GUARDIAN CONSENT
(if you are under 18)
Dear Parents:
York Hospital is pleased to welcome your child. If this meets with your approval, please fill out
and sign the form below. Thank you!
Sincerely,
Kate Ford
Kate Ford
Volunteer and Student Experiences
-------------------------------------------------------------------------------------------------------------------
To: York Hospital
My child, _______________________________________, has my/our consent to volunteer or
job shadow at York Hospital.
By signing this form I give my son or daughter permission to participate in York Hospital’s
Volunteer or Job Shadow Program. You have my permission to administer aid to my son or
daughter.
Parent/Guardian Signature: ___________________________ Date: ______________________
Emergency Contact Information
Name: ______________________________ Relation: ________________________________
Telephone: __________________________ Address: _________________________________
