Shadow Requst Form - East Alabama Medical Center

Please schedule at least two weeks in advance of your requested shadowing opportunity. Your request and application will be submitted to the Education Department. For more information on Job Shadowing/Observation at East Alabama Medical Center, please email the EAMC Education Center

Personal Info

Prefix

First Name

Last Name

At least 16?

Pending approval of (Department Manager)

Manager who approved

I have already been accepted by a department or manager to shadow

Contact Info

Street Address

Address Line 2

City

State

Zip

E-Mail

Home Phone

Cell Phone

School

Other School

Level of Education

Shadowing Info

Reason for Shadow

Number of hours interested in Shadowing

Goal or Expected Outcome of Shadowing

Department/Person of Interest for Shadowing (MUST BE PRE-APPROVED)

If other please explain

Emergency Contact Info

Emergency Contact

Emergency Contact Relationship

Emergency Home Phone

Emergency Cell Phone

Application to Shadow a Health Care Professional