Job Shadow Application

First Name:

Last

E-mail:

Phone:

Street Address

City

State / Province / Region

Postal / Zip Code

Name of school or program:

Current year in school:

Name of person or position you would like to shadow:

Preferred rotation site: Select value CWFM Yakima CHCW Ellensburg Clinic Ellensburg Dental Care Naches Medical Clinic Yakima Pediatrics Highland Clinic CHCW - Corporate

List your learning objectives for your job shadow experience:

Preferred date:

First Choice Begin Date:

First Choice End Date:

Second Choice Begin Date:

Second Choice End Date:

Once you have submitted this form you should receive an email confirmation that it has been submitted successfully.

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