Job Shadow Request

Job Shadow Request
Job Shadowing Requirements:

1. Must have filled out a MAHEC registration form within the last 12 months. If not, DO NOT fill this form out. Go to this link instead:

https://form.jotform.com/250296511864056

2. Must be at least 16 years of age.

2. Must have 4-8 hours available per job shadow. (If applying for NCMC Radiology program, they require 8 shadow hours).

3. Must complete the job shadow application process.

4. If requsting a shadow between dates of December 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.
Upload FLU VACCINE or exemption HERE:

Cancelof
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) 271-7199 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 …
I have already submitted the required HIPAA Test, Reflection and Confidentiality Forms.*

YesNo
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Current or most recent school attended*
Email*
example@example.com
Highest Grade Completed*
Expected Graduation Year*
Date of Birth*

MonthDayYear
Date
I am a current Mosaic caregiver.*

YesNoI would like for a Mosaic recruiter to contact me
Request:

Please specify the type of shadowing experience.
I would like to shadow someone in this facility (St. Joseph, Maryville, Albany):*
I would like to shadow this person (name):
I would like to shadow this department/field:*
I would like to shadow someone with this degree/certification:
Date Request:

Please choose dates that allow three weeks or more to set the schedule.
Date Option 1:*

MonthDayYear
MUST BE ATLEAST 3 WEEKS IN ADVANCE
Start Time to End Time:*
Ex: 9am-3pm (if flexible, enter that)
Date Option 2*

MonthDayYear
MUST BE ATLEAST 3 WEEKS IN ADVANCE
Start Time to End Time:*
Ex: 9am-3pm (if flexible, enter that)
Date Option 3*

MonthDayYear
MUST BE ATLEAST 3 WEEKS IN ADVANCE
Start Time to End Time:*
Ex: 9am-3pm (if flexible, enter that)
Should be Empty:

Job Shadow Request

21st Century Health Care is:

Request:

Date Request: