Shawano Application

Student Information:


Last Name: 


First Name: 


Address: 


Zip: 


Email: 


Current Grade: 


Home Phone: 


Cell Phone: 



Parent/Guardian Information:

Name(s):      

Address: 


Zip:   

Email:    


Cell:  

Home:    

Work:

What are your current plans after high school?


University
Trade School
Technical School

Get a job
Study Abroad
Volunteer
Unsure

What health career would you like to shadow?

Physician

  • Orthopedic Surgeon
  • Physiatry
  • Primary Care
  • Pediatrician
  • Radiologist
  • Anesthesiologist
  • Podiatrist
  • Optometrist
  • Dentist
  • Ear, Nose & Throat Specialist
  • Orthopedic Spine Surgery (patients in clinic)
  • Neurosurgery (patients in clinic)

Mid-Level

  • Nurse Practitioner
  • Registered Nurse
  • Physical Therapist
  • Occupational Therapist
  • Orthotist

Technician

  • Surgical
  • Radiology
  • Phlebotomy

From the list above, please list your top 3 career interests (#1 being your top choice).

The choices below are a guidance for your home base location where eight hours of shadowing will be offered. You will be given the opportunity to shadow in numerous other areas that are not on the above list (for example, pharmacy, oncology, dietician...).

1.   
2.   
3.   


Shadowing dates are between June and early August. Please list dates that you are NOT available for shadowing:

Please describe in a 250-500 word essay why you would like to participate in the Medical Mentoring Program, or upload text file below.



Student:


Parent:



Parent: