Job Shadow Application

Personal Details

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

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Zip Code

School Details

Name of School or Program *

Current Year in School *

Job Shadow Options

Name of Person or Position You Would Like to Shadow

Preferred Rotation Site

• CWFM Yakima
• Highland Medical Clinic
• CHCW Ellensburg Clinic
• Naches Medical Clinic
• Yakima Pediatrics
• Ellensburg Dental Care
• Senior Residential Care
• CHCW - Corporate

List your Learning Objectives for your Job Shadow Experience: *

Preferred Start and End Dates

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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