YOUTH-MED® Shadows (Enrollment Packet)

YOUTH-MED® Shadows (Enrollment Packet)
NGHS ACEMAPP Portal Access
Shadowing at NGHS partner sites requires an ACEMAPP account and submitted application. Create your account and submit your application in the NGHS ACEMAPP portal, then confirm below. ACEMAPP takes about two days to process, so complete it first.
Have you created your ACEMAPP account?
Have you submitted your ACEMAPP application?
Email/username used for ACEMAPP
Northside Hospital Observer Form
Clinical shadowing at Northside Hospital requires a completed Application for Medical Observer. Download the form, complete and sign it, then upload the signed copy here. Leave the Sponsoring Physician section blank — HHCP coordinates the sponsoring physician signature.
Upload your signed Northside Observer form

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Health Clearance Documents
Partner sites require proof of a current negative TB test and immunization records before shadowing. Upload both below, or email them to youthmed@hhcpinc.org.
Upload TB test result

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Upload immunization records

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Shadow Placement Preferences
Which days are you available to shadow)?
What is your general availability for shadow placements?
Preferred clinical areas or specialties (e.g., Interventional Radiology, Clinic, Hospital, etc.)
Anything else we should know for your placement (transportation, scheduling constraints, etc.)?
Welcome to YOUTH-MED® Shadows, the year-round continuation of your YOUTH-MED® journey.

A note on eligibility: YOUTH-MED® Shadows is open to scholars age 16 and older. 'YOUTH' in YOUTH-MED® reflects where you are in your career journey, not only your age. Our scholars range from college through graduate and professional school. If you are 18 or older, pre-professional, and exploring or preparing for a healthcare career, and you have not yet entered your field as a credentialed, practicing professional, you are a YOUTH-MED® scholar.
Scholar Information
Career Journey Status
I confirm that I am 16 years of age or older.
How did you qualify for YOUTH-MED® Shadows?
Briefly describe your HHCP involvement (scholarship year, volunteer role, program, approximate dates)
Scholar Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Grade or Status
Current School / Institution
YOUTH-MED History
Year you first joined YOUTH-MED (original entry year)
Which YOUTH-MED pathway(s) did you complete?

Other
Health & Safety Attestation
I understand that some partner sites require proof of a current negative TB (tuberculosis) test and/or immunization records before shadowing. I agree to provide any health clearance documentation a partner site requires prior to my assigned shadow date.
I am not knowingly experiencing any contagious illness on the day of a scheduled shadow, and I agree to stay home and reschedule if I am unwell.
HIPAA & Confidentiality Acknowledgement
I understand I may be incidentally exposed to confidential patient information and protected health information (PHI) during observation. I agree never to photograph, record, repeat, share, or document any patient information. I understand that observation does not give me access to medical records or electronic health systems, and that any breach of confidentiality will result in immediate removal from the program.
Assumption of Risk & Release of Liability
I acknowledge that participation in clinical observation involves inherent risks, including exposure to clinical environments. I voluntarily assume these risks. On behalf of myself, I release and hold harmless Help for Healthcare Professionals, Inc. (HHCP), its partner sites, and their staff from any liability for injury, illness, or loss arising from participation, except in cases of gross negligence or willful misconduct.
Photo & Media Release
Photo & Media Release
I authorize HHCP to share my enrollment information (name, age, pathway, career goals, assigned shadow date, emergency contact, and any required health clearance status) with approved partner sites solely for the purpose of coordinating my shadow placement.
I agree to abide by the YOUTH-MED® Code of Conduct, including professional dress, punctuality, and respectful behavior, and I understand HHCP may remove any scholar whose conduct is disruptive, unsafe, or unprofessional.
I certify that the information I have provided is true and accurate, and that my electronic signature below has the same legal effect as a handwritten signature.
Yes, enroll me in the monthly YOUTH-MED® Career Connect Access Sessions to stay connected, hear from healthcare professionals, and access ongoing opportunities.
Consent and Acknowledgement
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that YOUTH-MED® Shadows places scholars in observation-only clinical settings at partner sites. I agree to follow all partner site policies, dress code, and professional conduct expectations. I understand shadowing is observation only and does not involve direct patient care.
I agree to self-report my shadow hours through the YOUTH-MED hour-tracking platform provided to me after enrollment.
Scholar Signature
Should be Empty:

YOUTH-MED® Shadows (Enrollment Packet)

NGHS ACEMAPP Portal Access

Northside Hospital Observer Form

Health Clearance Documents

Shadow Placement Preferences

Scholar Information

YOUTH-MED History

Health & Safety Attestation

HIPAA & Confidentiality Acknowledgement

Assumption of Risk & Release of Liability

Photo & Media Release

Consent and Acknowledgement