Student Application for Job Shadowing Student Information Your full name Today's date Your email address * Date of Birth Are you employed? Yes Yes No No Is this placement required by School Yes Yes No No Placement Information What hours do you prefer? Full Days Full Days Half Days Half Days Under the terms of the internship, it is understood that the student is under the direct supervision of department manager. Any patient care delivered by the student will be under the direction of the department manager or his/her designee and only after student competency has been established and possession of school/personal liability insurance has been confirmed. The department manager will secure informed consent from the patient to permit the student to participate appropriately in the provision of patient care. Department managers will accept total responsibility for the supervising and directing those students who wish to serve internships with them in the Hospital. The student understands and accepts the internship experience as described above. The student agrees to abide by the rules and regulations of River Hospital. Please type in your full name as a digital signature Today's date Submit