Job Shadow

Job Shadow Request Form
Name*

First NameLast Name
Age*
Date of Birth*
MaleFemalePrefer Not To Answer
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If you are sending this request form working within a school program, please state what school and what program:
Please list any scheduling issues (if applicable) that may conflict with Thompson Veterinary Clinic’s job shadow schedule:
For Individuals Under the Age of 18
Parent or Legal Guardian’s Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
Email
example@example.com
Emergency Contact
Name*

First NameLast Name
Relation to Job Shadow*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Food or Other Know AllergiesAsthmaSeizuresHeart ConditionVision ImpairmentHearing ImpairmentMobility ImpairmentOther ConcernsNo Concerns
If chose "other concerns", please explain:*
Please list any behaviors/special needs staff should be aware of:*
Please list any medications Job Shadow is taking:*
YesNo
Release of Liability

Job shadows and/or parents and guardians of job shadows under the age of 18 are required to read all of the following information and sign below.
I understand and acknowledge that participation in Job Shadowing could pose a risk to me or any individual. I discharge Thompson Veterinary Clinic and all officers, directors, employees, agents and volunteers of the organization, acting officially or otherwise, from any and all claims, demands, actions, or causes of action in which any way arises from my or my minor’s participation in Job Shadowing with Thompson Veterinary Clinic.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 any photograph/video that is taken in which my child or myself is included while participating in the Job Shadow Program to be posted for publicity reasons.I hereby certify that to the best of knowledge or belief my child or myself is in good health and able to participate in Thompson Veterinary Clinic Job Shadowing.I hereby certify that this firm is complete and accurate to the best of my knowledge.
The undersigned acknowledges that all participations in job shadowing through Thompson Veterinary Clinic 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, types of projects performed, weather conditions, etc. in general. In consideration of job shadowing with Thompson Veterinary Clinic permitting the named volunteer participate, 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 Thompson Veterinary Clinic and its respective officers, employees, agents volunteers, and representatives there of hereinafter referred to as releases, which in any way arises out of or is related to participation of job shadowing through Thompson Veterinary Clinic.

This includes the Release and Waiver, without limitation for DAMAGE OF PROPERTY, OTHER LOSS OR DAMAGE, or PERSONAL INJURY OR DEATH the undersigned may suffer from any cause whatsoever related to participation of job shadowing through Thompson Veterinary Clinic. 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 job shadowing through Thompson Veterinary Clinic, 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 ambulatory 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 to any claim for death, personal injury, damage to property or any damage caused by the undersigned's participation in job shadowing through Thompson Veterinary Clinic.

As the undersigned participating, I agree to following Thompson Veterinary Clinic policies and procedures. (please sign below)
Type Signature*
Date Signed*
Type Parent/Guardian Signature
if applicable
Date Signed
Certification Release
I certify that the health information provided to Thompson Veterinary Clinic is accurate to the best of my knowledge. I am aware that volunteering to job shadow through Thompson Veterinary Clinic may reuire 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. Thompson Veterinary Clinic encourages job shadows to have physical examinations by their physicians prior to job shadowing at the facility.

This is to certify that I have read, understood, and agree TO THE TERMS OUTLINED IN THE ABOVE Release of Liability and Certification and Release.
Type Signature*
Date Signed*
Type Parent/Guardian Signature
if applicable
Date Signed
Should be Empty:

Job Shadow Request Form

For Individuals Under the Age of 18

Emergency Contact

Release of Liability

Certification Release