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  • PARTICIPANT CONTACT INFORMATION

    PARTICIPANT CONTACT INFORMATION

  • MAHEC is required to report general demographic information about participants.This data will be confidentially maintained and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form.

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  • K-12 PARENT/GUARDIAN INFORMATION

  • CURRENT SCHOOL INFORMATION

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  • SURVEY

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  • Job Shadow Release and Waiver of Liability

  • This Job Shadow Release and Waiver of Liability ("Release") is executed on

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  • ("Job Shadow") in favor of Mosaic Health System, including any affiliates under common control with or by Mosaic Health System and their directors, officers, employees, agents, and insurers ("Mosaic").

  • I, Job Shadow, desire to participate in job shadowing at a Mosaic facility in order to gain exposure to the job duties and environment of certain positions within Mosaic and so that Mosaic may gain a greater introduction to me and a fuller understanding of my interest in the organization (the "Activities"). As a Job Shadow, I understand that the scope of this type of relationship with Mosaic is limited and that, as such, no compensation or other benefits traditionally associated with employment are expected in return for the Activities performed.

    To my knowledge, I am in good health and suffer no mental or physical impairment that would or should prevent my participation in the Activities. I will not come onsite to a Mosaic facility and will notify my Mosaic contact and/or recruiter in the event I am feeling ill or otherwise experiencing any of the screening symptoms of the 2019 novel coronavirus disease (COVID-19) as outlined by Mosaic and updated from time to time based upon recommendations and guidelines from the Centers for Disease Control and Prevention and the Department of Health and Senior Services. In consideration for being allowed to participate in the Activities at Mosaic, execute this Release under the following terms:

    1. Assumption of Risk. I am aware of the highly contagious nature of COVID-19. While I will not participate in the administration of patient care, I am aware of the risk that I may be exposed to or contract COVID-19 by engaging in the Activities, which may include, but are not limited to, maintaining close or direct contact with patients, visitors, staff, or other individuals at Mosaic through the observation of patient examination, consultation, treatment, surgical processes, or other healthcare-related work. I understand that contracting COVID-19 may result in serious illness, prolonged hospitalization, injury, disability, or death, as well as the potential spread to other individuals. I acknowledge that these risks may result from or be compounded by the actions, omissions, or negligence of Mosaic or others. I understand that while Mosaic has implemented measures to reduce the risk of injury from the Activities and the spread of COVID-19, Mosaic cannot guarantee that I will not be injured or become infected with COVID-19 due to my participation in the Activities. I hereby expressly and specifically assume the risk of injury or harm from these Activities and release Mosaic from all liability for injury, illness, death, or property damage resulting from the Activities.

    2. Insurance. I understand that Mosaic does not assume any responsibility for or obligation to provide financial assistance or other assistance, including, but not limited to, medical, health, or disability insurance in the event of my injury or illness. Each job shadow is expected and encouraged to obtain his or her own medical, health, and/or disability insurance coverage. I expressly waive any such claim for compensation or liability on the part of Mosaic beyond what may be offered freely by Mosaic in the event of such injury or medical expense.

    3. Medical Treatment. I hereby release and forever discharge Mosaic from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with my Activities with Mosaic.

    4. Release and Waiver. I do hereby release and forever discharge and hold harmless Mosaic and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my Activities with Mosaic. I UNDERSTAND THAT THIS RELEASE DISCHARGES MOSAIC FROM ANY LIABILITY OR CLAIM THAT I MAY HAVE AGAINST MOSAIC WITH RESPECT TO BODILY INJURY, PERSONAL INJURY, ILLNESS, DEATH, OR PROPERTY DAMAGE THAT MAY RESULT FROM MY ACTIVITIES WITH MOSAIC, WHETHER CAUSED BY THE NEGLIGENCE OF MOSAIC OR OTHERWISE.

    5. Media Release.  I hereby consent to and authorize the Releasees to take, use, and disclose photography, video, and audio recordings of me and interviews conducted with me during the Activities, which may include my name and biographical information, (my “Likeness”) for educational purposes, advertising, publicizing, or marketing their programs, services, and facilities, or for any other commercial or lawful purposes related to their organizational missions without compensation to me.  I waive the right of approval or inspection and authorize my Likeness to be copied and disclosed through print, broadcast, social, sound, or digital medial channels both internal and external to the Releasees, without any geographical limitation.  I understand and agree that materials containing my Likeness will become the property of the Releasees and will not be returned to me and that these uses and disclosures of my Likeness may result in financial or in-kind compensation to the Releasees by a third party.    

    6. Other. I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Missouri and will be governed by and interpreted in accordance with the laws of the State of Missouri. I also agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions will not be affected.

     

  • I HAVE CAREFULLY READ THIS JOB SHADOW WAIVER AND RELEASE OF LIABILITY, AM RELYING SOLELY UPON MY OWN JUDGMENT WITHOUT INFLUENCE BY ANYONE, FULLY UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING, AND NOW FREELY AND VOLUNTARILY SIGN WITHOUT ANY INDUCEMENT.

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  • Confidentiality Statement

  • I understand and agree that in the performance of my duties as a job shadowing student in the medical facility, I must hold medical information on patients and information regarding hospital personnel or medical staff members in complete confidence. I have read and understood the shadowing guidelines and will comply with the expectations of a shadow.

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  • Student Contact Information

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  • Contact Information

    In case of a medical emergency, the staff of your shadow location must be able to contact a parent/guardian or other emergency contact at all times during the program.
  • Parent/Guardian:

  • Other Contact:

  • Shadowing Assessment

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  • Part 1: Etiquette, HIPAA and Confidentiality

  • Read each question below. Select all correct answers for each question below.

  • Part 2: Self Reflection

  • Job Shadow Request

  • Job Shadowing Requirements: 

    1. Must be at least 16 years of age.

    2. Must have 4-8 hours available per job shadow.

    3. Must complete the job shadow application process. 

    4. Between dates of October 1 - March 31 (flu season), anyone 18 years of age and older is required to have their flu vaccine with proof of documentation or exemption. You must email documentation or exemption to nwmoahec@mymlc.com or attach below before your shadow will be scheduled.

     

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  • We are happy that you are interested in job shadowing a caregiver and have taken the time to prepare yourself for the experience. Please complete the form below and submit your request.

    Email Confirmation: Within 2-3 weeks of submitting all required documents, you will receive a confirmation email with further instructions. If you do not receive an email acknowledgment in that time frame:

    Check your junk/spam email folders for a message from nwmoahec@mymlc.com.
    Send an email inquiry to nwmoahec@mymlc.com.
    Call (816) 271-6769 to inquire about the request.

  • 21st Century Health Care is:

  • Dental Hygiene

    Dentistry

    Dietetics

    Diagnostic Imaging

    Health Administration

    Health Informatics

    Laboratory

    Medicine

    Nursing

    Occupational Therapy

    Osteopathic Medicine

    Pharmacy

    Physical Therapy

    Psychological Counseling

    Public Health

    Social Work

    Speech Therapy

    Rehabilitative Services

    and more …

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  • Request:

    Please specify the type of shadowing experience.
  • Date Request:

    Please choose dates that allow two weeks or more to set the schedule.
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  • Should be Empty: