Observation & Shadowing Application

Name
Address

Students are responsible for communicating and securing sponsor before filling out application. 

Your sponsor is the provider you will actively shadow when you come to complete your observation hours. 

Additional sponsor(s) may be added after application submission. Please inform us via email the names of any other sponsors. There is no need to submit a second application to add more sponsors in the same year.

Do not enter N/A into this field. You must enter the name of the Sponsor you will shadow.

Eg. Johnson City Medical Center, Bristol Regional Medical Center or Indian Path Community Hospital.
(Maximum: 80 hours per sponsor)
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.