Request Form for College Student Shadow Program at UPMC in Central Pa.

UPMC in Central Pa.’s shadowing program allows college students age 18 or older who are planning a career in a specific health care field to observe the responsibilities and duties of hospital personnel, such as speech pathologists, medical technologists, physical therapists, occupational therapists, nurses and radiology technologists.

By submitting this form, I plan to observe a health care worker at UPMC in Central Pa. entity to help facilitate a selection of a career. I will assume full responsibility and/or medical costs for an accident or injury incurred to me during transportation to and from the time spent at UPMC in Central Pa., as well as during the observation period.

By submitting this form, I agree to maintain the requirements as indicated by the UPMC in Central Pa. College Shadow Program Confirmation Letter.

First Name Last Name Email Address Phone Number Date of Birth College/University Program/Major Are you currently a UPMC employee? Yes No Location where you prefer to shadow (check all that apply): UPMC Carlisle UPMC Community Osteopathic UPMC Hanover UPMC Harrisburg UPMC Lititz UPMC Memorial UPMC West Shore Department and title/role you prefer to shadow. Please provide two dates of availability. Have you contacted a UPMC employee who has pre-approved your shadow experience? If so, please provide their name and department. (Optional)

I understand that by providing my email address, I agree to receive emails from UPMC. I understand that I may opt out of receiving such communications at any time.

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