Waiver - High School - St. Anthony's Medical Center

JOB SHADOWING AGREEMENT/WAIVER
By signing this document, we demonstrate that we understand and agree to the following:
• We understand that St. Anthony’s Job Shadowing Program is a community service designed
to enable students to observe medical center employees to gain insight into health care careers.
• The student named below is up-to-date on his/her “childhood” immunizations, such as
MMR (measles, mumps and rubella) and DPT (diptheria, pertussis and tetanus).
• The student will report promptly at the time and location assigned. We understand that the
shadowing period may be shortened or terminated due to unforeseen circumstances in the
department or if the student’s behavior or dress is inappropriate. We understand that
inappropriate conduct or dress will be reported to the student’s high school job shadowing
coordinator.
• The student will dress in appropriate clothing. (Males must wear slacks and females must
wear slacks or an appropriate skirt or dress. Jeans, shorts, mini-skirts and T-shirts are not
permitted.) We understand that if the student does not dress in appropriate attire, he/she will
be asked to leave and the job shadowing experience will be canceled, unless the student can
change clothes and return.
• The student will follow the instructions of the employee being shadowed.
• The student will observe only and will not assist in patient care activities.
• We acknowledge St. Anthony’s mission:
“St. Anthony’s, a Catholic medical center, has the duty and the privilege to provide the best care to every patient,
every day.”
• We acknowledge that all medical, financial and personal information pertaining to a patient
is confidential and is protected from unauthorized viewing, discussion and disclosure.
Therefore, the student job shadower may look at patient information ONLY as it relates to the
job shadowing experience. Any unauthorized viewing, discussion or disclosure will provide
grounds for immediately terminating the job shadowing experience. When it is questionable as
to what information is confidential, it is the student’s responsibility to discuss the matter with
the employee being shadowed.
• This agreement is between the undersigned parent/legal guardian, participant and St.
Center.

• The undersigned parent/legal guardian and participant assume all risks of any nature
whatsoever and do hereby release and forever discharge St. Anthony’s Medical Center, its
officers, directors, employees and agents from claim of liability for any injury/accident
occurring on the premises of St. Anthony’s Medical Center.
• The undersigned participant is not afforded protection under the facility’s worker’s
compensation or health agency’s care program; any expenses other than initial urgent
care/emergency department examination or treatment shall be borne by the participant and
parent/legal guardian. In the event of an emergency, the participant’s parent/legal guardian
will be notified.
• The parties agree that under no circumstances is the participant to be considered an agent or
employee of St. Anthony’s Medical Center.
• No individual will be discriminated against on the basis of race, sex, age, creed or national
origin, in any respect.
• The parties have executed this agreement effective as of the day and year indicated below.
_________________________________ ______________________________ _________________
Participant’s signature Participant’s name (printed) Date
_________________________________
Participant’s high school
______________________________
Home phone number
___________________________________ __________________________________________
Parental Consent/Guardian
SAMC coordinator’s signature
Revised 3/08