Welcome to Rochester General Hospital Volunteer Services Department

Shadowing Application

Name prefix
First name
Middle Initial
Family/last name
Gender
DOB
Application date
High School
College/University
Home address
Street
Apt
City
State
Zip/postal
Home phone
Mobile
E-mail
Work phone
Emergency Contact
Contact name
Relationship
Home phone
Work phone
Shadowing Information
Who Will You Be Shadowing?
First Name
Last Name
Title (Dr, PA, Nurse, etc.)
Have you already received permission to shadow this person?
If "no," please obtain approval before completing/submitting this application.
Shadowing Start Date
Shadowing End Date
From start to end date, my shadowing experience will be:
5 days or less
One week or longer

Please read and sign: I understand that any falsification of information on this application may result in immediate termination of the application/on-boarding process or the privilege of shadowing/volunteering with Rochester Regional Health. I authorize the Volunteer Services Department to contact any references that I may provide in the application and on-boarding process. If I am required to complete the health screening and medical examination process or any other requirements, I agree that my acceptance is contingent upon my passing these required steps. I understand that while shadowing/volunteering, I am expected to observe confidentiality with respect to all patient information at all times, and that failure to do so may result in my personal liability to the patient and/or the hospital.
I agree

For office use only:
Health Screening
Background Check
Wheelchair Training
Orientation