North Buffalo AH - Internship and Job Shadowing Form

Job Shadow, Internship & Preceptorship Application Form
1606 Kenmore Avenue, Buffalo, NY 14216

Phone: (716) 876-6023

Email: info@northbuffaloah.com
Welcome

Thank you for your interest in North Buffalo Animal Hospital. We are pleased to offer educational opportunities for individuals interested in veterinary medicine through job shadow experiences, internships, and veterinary technician preceptorships.Our team is committed to providing a meaningful learning experience while maintaining the highest standards of patient care, client service, professionalism, and confidentiality. Participation opportunities are offered on a first-come, first-served basis. To ensure a quality educational experience, North Buffalo Animal Hospital generally hosts only one internship or preceptorship participant at a time.Please complete this packet in its entirety and submit all required supporting documents. Incomplete applications will not be considered.
APPLICANT INFORMATION
Applicant Type (Check One)
Name

First NameLast Name
Date of Birth
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
SCHOOL INFORMATION
Education Level
School Name
Program/Major
School Contact Person
Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If this experience is required for coursework or program completion, please provide the name of an actual school representative rather than a general school contact.
EMERGENCY CONTACT & MEDICAL INFORMATION
Emergency Contact

First NameLast Name
Relationship
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
MEDICAL INFORMATION
Please list any severe allergies (including medication allergies), chronic medical conditions, restrictions, accommodations, concerns, or special needs of which we should be aware:
EDUCATIONAL & EXPERIENCE QUESTIONNAIRE
How did you hear about North Buffalo Animal Hospital?
Why are you interested in completing a job shadow, internship, or preceptorship at North Buffalo Animal Hospital?
When and how did you become interested in veterinary medicine?
What are your educational and career goals?
Describe any veterinary, animal-care, volunteer, employment, leadership, or extracurricular experience that may be relevant to this opportunity.
What do you hope to learn during your experience at North Buffalo Animal Hospital?
AVAILABILITY & PROGRAM REQUIREMENTS
What dates and times are you available
How long are you interested in participating with us?
If this experience is through a school program, how many hours are required?
Are you covered by personal insurance and/or your school’s insurance policy?
If yes, please explain:
PROGRAM INFORMATION
Eligibility Requirements

Participants must be at least 16 years of age to participate in a job shadow, internship, or preceptorship experience at North Buffalo Animal Hospital.

Internship Duration Guidelines

Attendance Expectations

Our business day begins at 8:00 a.m. Participants are expected to arrive on time, maintain professional behavior, and actively engage in the learning experience.
For the best educational experience, participants are encouraged to attend full-day sessions whenever possible to observe patient care and workflow throughout the day.
ATTIRE REQUIREMENTS
Job Shadow & General Internship Participants
- Comfortable closed-toe, rubber-soled shoes
- Scrubs are HIGHLY recommended
- Khaki-style pants or other professional attire
- Professional/Business Shirt
- Clothing that may become dirty
Veterinary Technician Preceptorship Students
- Professional scrubs (please avoid gray scrubs)
- Comfortable closed-toe, rubber-soled shoes
HOSPITAL HOURS
REQUIRED DOCUMENTS CHECKLIST
Please submit the following:
Applications that are incomplete will not be considered.
File Upload

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WAIVER OF LIABILITY, ASSUMPTION OF RISK, CONFIDENTIALITY AGREEMENT & PHOTO RELEASE
I agree to participate in a job shadowing, internship, or preceptorship experience provided by North Buffalo Animal Hospital (“NBAH”), located at 1606 Kenmore Avenue, Buffalo, NY 14216.
I understand that participation is voluntary and may involve exposure to animals, animal bites, scratches, zoonotic diseases, pathogens, allergens, cleaning products, veterinary equipment, and other workplace hazards that could result in illness, injury, disability, or death.

I knowingly and voluntarily assume all risks associated with participation.

I hereby release, waive, and forever discharge NBAH and its owners, administrators, officers, employees, agents, and representatives from any and all claims, damages, liabilities, losses, or causes of action arising from participation, including claims alleged to result from negligence, to the fullest extent permitted by law.

I certify that I maintain medical insurance coverage and understand that I am solely responsible for any medical expenses not covered by my insurance provider.
Signature
Date

MonthDayYear
Date
Confidentiality Agreement
I agree to maintain strict confidentiality regarding all information observed or learned during my experience, including but not limited to:
- Client information
- Patient information
- Medical records
- Financial information
- Business operations
- Proprietary information
I will not photograph, video record, copy, disclose, or post any confidential information, clients, patients, procedures, or hospital activities on social media or any public platform.

All records, documents, and materials remain the exclusive property of North Buffalo Animal Hospital.
Photo Release
I authorize North Buffalo Animal Hospital to use my name, photograph, image, or likeness for educational, recruiting, marketing, or promotional purposes without compensation or further approval.
Acknowledgement
I certify that all information provided in this application packet is true and accurate.

I acknowledge that I have carefully read this entire document, understand its contents, understand that I am waiving certain legal rights, and voluntarily agree to all terms and conditions contained herein.
SIGNATURES
Applicant Printed Name

First NameLast Name
Applicant Signature
Today's Date

MonthDayYear
Date
Parent/Guardian Printed Name (Required if Applicant is Under 18)

First NameLast Name
Parent/Guardian Signature
Today's Date

MonthDayYear
Date
OFFICE USE ONLY
Date Application Received

MonthDayYear
Date
Applicant Type
Type a question
Assigned Mentor
Scheduled Dates
Hours Required
Additional Notes
Should be Empty:

Job Shadow, Internship & Preceptorship Application Form

Welcome

APPLICANT INFORMATION

SCHOOL INFORMATION

EMERGENCY CONTACT & MEDICAL INFORMATION

MEDICAL INFORMATION

EDUCATIONAL & EXPERIENCE QUESTIONNAIRE

AVAILABILITY & PROGRAM REQUIREMENTS

PROGRAM INFORMATION

ATTIRE REQUIREMENTS

HOSPITAL HOURS

REQUIRED DOCUMENTS CHECKLIST

WAIVER OF LIABILITY, ASSUMPTION OF RISK, CONFIDENTIALITY AGREEMENT & PHOTO RELEASE

Confidentiality Agreement

Photo Release

Acknowledgement

SIGNATURES

OFFICE USE ONLY