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Request Form for the Advanced Practice Providers (APP)/Physicians Shadow Program
at UPMC in Central Pa.

By submitting this form, I request to observe a health care worker at UPMC in Central Pa. entity to help facilitate my selection of a career. I assume all risks of my participation, accept full responsibility and/or medical costs for, and hereby waive any claims or rights against UPMC, its parents, affiliates, subsidiaries, officers, employees, agents, or representatives that I might have related to, any accident, illness, injury, or other harm or loss incurred by me during, or as a result of, transportation to and from UPMC and/or the time spent at UPMC in Central Pa., including but not limited to 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.

All fields are required unless noted otherwise.

I understand that by checking the box above, I agree to receive emails from UPMC. I understand that I may opt out of receiving such communications at any time.