Gilbertsville Vet - Job Shadow Application

Job Shadow Application

Release of Liability and Permission Form

Date*

Date

Name*

First NameLast Name

Age

Gender*

MaleFemale

Date of Birth

Date

Parent/Guardian

First NameLast Name

Phone Number

Area CodePhone Number

Email*

example@example.com

Emergency Contact Details

Name

First NameLast Name

Relationship to Job Shadow

Phone Number

Area CodePhone Number

Please complete the following medical information and explain if necessary: Does the Job Shadow have any of the following? ( Please select all that apply )

List any other concerns

Please list any behaviors/special needs staff should be aware of

Please list any medications Job Shadow is taking

Is your Tetanus shot up to date?

YesNo

Is your Measles, Mumps, Rubella up to date?   

YesNo

RELEASE OF LIABILITY*

I understand and acknowledge that participation in the Job Shadow Program could pose a risk to me or any child. I discharge Gilbertsville Veterinary Hospital and all officers, directors, employees, agents and volunteers/interns of the organization, acting officially or otherwise, from any and all claims, demands, actions, or causes of action in which any way arise from my or my minor’s participation in the Job Shadow Programs with Gilbertsville Veterinary Hospital.I give permission for my child or myself to be treated by a health provider, first aid response, health supervisor, and/or hospital in case of an emergency.I give permission for photographs and/or video to be taken of my child or myself while participating in the Job Shadow Program. Any photographs or video taken will be used for publicity purposes only.I hereby certify that to the best of knowledge and belief my child or myself is in good health and able to participate in Gilbertsville Veterinary Hospital Job Shadow Program.I hereby certify that this form is complete and accurate to the best of my knowledge.

The undersigned acknowledges that all participations in Gilbertsville Veterinary Hospital Job Shadow Program is a potentially dangerous activity involving RISK OF PERSONAL INJURY, PROPERTY DAMAGE, DEATH. Such risk may increase based upon any changes in number of guests and volunteers, types of projects performed, and weather conditions, etc. in general. In consideration of the Job Shadow Program with Gilbertsville Veterinary Hospital permitting the named volunteer to participate in the Job Shadow Program, I hereby agree as follows:

The undersigned hereby RELEASES AND WAIVES any and all RIGHTS AND CLAIMS of any nature which said undersigned has or may have against Gilbertsville Veterinary Hospital and its respective officers, employees, agents, volunteers and representative there of hereinafter referred to as Releases, which is any way arises out of or is related to participation in Gilbertsville Veterinary Hospital Job Shadow Program.

This includes the Release and Waiver, without limitation for DAMAGE TO PROPERTY, OTHER LOSS OR DAMAGE, or PERSONAL INJURY OR DEATH the undersigned may suffer from any cause whatsoever related to participation in Gilbertsville Veterinary Hospital Job Shadow Program. The undersigned assumes FULL RESPONSIBILITY for any and ALL RISK OF ANY BODILY INJURY, PROPERTY DAMAGE, OR DEATH which the undersigned may suffer while participating in Gilbertsville Veterinary Hospital Job Shadow Program, whether due to weather conditions or weather-related conditions, animals at the hospital and/or participants or ANY other causes. I further agree that I am solely responsible for payment of all costs resulting from rendering medical aid and ambulance services to the participant and I authorize that all necessary first aid steps may be taken as prescribed by qualified personnel.

The undersigned agrees to DEFEND, INDEMNIFY AND HOLD RELEASES HARMLESS from any and all liability, damage, cost or expense (including but not limited to attorney and witness fees) which may be incurred or suffered by them on account of any claim for death, personal injury but not limited to attorney and witness fees) which may be incurred or suffered by them on account of any claim for death, personal injury, damage to property or any damage caused by the undersigned’s participation in Gilbertsville Veterinary Hospital Job Shadow Program.

As the Parent/Guardian of job shadow participating I agree to following Gilbertsville Veterinary Hospital Job Shadow Policies and Procedures: (Please sign and date at the bottom)

Certification Release*

First NameLast Name

I certify that the health information provided to Gilbertsville Veterinary Hospital is accurate to the best of my knowledge. I am aware that volunteering with Gilbertsville Veterinary Hospital Job Shadow Program may require vast levels of exertion. I know that a Job Shadow may be required to lift fifty pounds, and work with animals that may at times be unpredictable. Gilbertsville Veterinary Hospital encourages Job Shadows to have physical examinations by their physicians prior to job shadowing in the program.

This is to certify that I have read, understood and agrees TO THE TERMS OUTLINED IN THE ABOVE Release of Liability and Certification and Release.

Date*

Date

Parent/Guardian Signature*

DiSC Questionnaire

While I am working, it is most important for me to

Help my coworkers and feel there is a cohesive environment.Communicate with my coworkers and have a good relationship.Know exactly what is expected of me and finish one task before moving to another.Get things done and see results.

When I hear an opinion from someone and I do not agree with it, I tend to

Ask them for more information.Not say anything to keep things calm.Talk about their opinion to see where they are coming from.Let them know at the moment that I disagree.

When I am working on a team and we run into a bump in the road, I will most likely say

We should make a decision and quickly move forward. Not everyone agrees all the time.How do you feel? I want to make sure that we are all comfortable.Why don’t we just talk it out together and come to a decision?Let’s consider this situation more carefully. Do we have all of the information we need to move forward?

My opinion toward detailed work such as data and analysis would most often be

It is great! I love it!If it will help other people/make things run smoothly then I would do it.Not for me! It is important, but I would rather talk through things than researching them.Not my favorite, but I would do it for a faster outcome in a situation.

When I am in a social situation with people I have not met before, I would most likely

Find a person or two that I have met before or might be comfortable with and talk with them quietly.Be determined to seek out people that would give me the most result as an outcome of being in the social situation.Find enjoyment in meeting and talking with as many people as possible before departing from the social situation.Quietly observe the situation from afar and only engage when someone talks to me.

The way that others would likely describe me is

Self-assured, accomplished, results-drivenLogical, accurate, orderlyGood listener, generous, neighborlyFriendly, enthusiastic, chatty

When I hear that something will be changing, I will most likely think

Is there a good reason behind the change?How will this change affect speed and results?We should talk about this change out to make sure it is best.Hopefully, everyone is on the same page with moving forward that way.

A new project is being started at work. Your first thought is

I wonder if anyone would like to work on this project with me?The details of this project will be important to be successful.How can we get this project completed the most efficiently?A steady approach will be the best way to tackle this project.

What I enjoy the most in a work environment would be

The opportunity to interact with others.Working independently to produce accurate results.Taking actions that could support the team as a whole.Fast-paced work to achieve goals.

The tasks and/or projects that I enjoy the most would involve

Doing what I already know at my own pace.Researching and deciphering information to aid in making decisions/a plan.Making quick decisions and achieving big results.Working with as many people as I could on the project to collaborate.

Job Shadow Application

Liability Release