Schreiber: Student Shadow Application

Schreiber: Student Shadow Application
If you are completing this application and are under the age of 18, please have a parent or guardian with you to sign the necessary sections.
Legal Name

First NameLast Name
Preferred Name (if different from Legal Name)
Preferred Pronouns
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (mobile preferred)
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
EMERGENCY CONTACT: Name

First NameLast Name
EMERGENCY CONTACT: Email
example@example.com
EMERGENCY CONTACT: Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT: Relationship to Volunteer

Other
School Name
Current Grade
Do you need to fulfill a school requirement?
If yes, please identify the type of requirement to be fulfilled.

Other
How many hours do you need to complete? (For a career shadow, we can provide up to 10 hours of observation or half of the hours your school mandates. )

Availability (Check all that apply). We offer shadowing Monday - Thursday from 8 am to 7 pm.

Rows	Mon	Tues	Wed	Thurs
Morning (8 am to 2 pm)
Afternoon/Evening (2 pm to 7 pm)

Please list any dates you are NOT available.
Areas of Interest (Check all that apply)

Other
I understand that this is an application and not a commitment or promise of a shadow opportunity. I am aware that job shadow opportunities require me to produce current copies (valid within the past five years) of the PA Child Abuse History and PA State Police Criminal Background Check. I acknowledge that any and all costs associated with said clearances is my responsibility.
Applicant Signature
Parent/Guardian Signature (if applicant is under 18 years of age)
Date

MonthDayYear
Date

Please Upload Required Clearances
PA Child Abuse History Clearance

Cancelof
PA State Police Criminal History Clearance

Cancelof

Shadow Student Agreement

Please review this information in its entirety and acknowledge receipt and agreement with your signature below.
Shreiber Center for Pediatric Development is committed to fostering educational opportunities for students interested in healthcare, therapy, education, and related professions. Our student shadowing program provides individuals with the opportunity to observe experienced professionals in a pediatric setting and gain insight into the delivery of interdisciplinary services for children and families.

The purpose of this Student Shadowing Agreement is to establish clear expectations, responsibilities, and guidelines for participation in the shadowing experience. Through observation, students may gain a better understanding of professional roles, clinical practices, and the importance of compassionate, family-centered care.

Because Schreiber serves children and families in a healthcare environment, all student observers are required to maintain the highest standards of professionalism, confidentiality, safety, and respect. Participation in the shadowing program is contingent upon compliance with all Schreiber policies, applicable privacy laws, and the terms outlined in this agreement.

Learning Outcomes

During your time with us, you’ll have the chance to:
- Observe therapy sessions
- Explore the tools and resources our therapists use
- Ask questions and learn directly from our experienced team
Dress Code

Our dress code is casual, but closed toe shoes are required, and we ask that you avoid:
- Jeans with holes
- Shorts
- Sweatpants
- Crop tops
- Clothing with controversial or inappropriate wording
Important Notes
- You are responsible for bringing and managing any paperwork required by your school. If you have any paperwork that needs to be signed by one of our therapists, please inform us at the start of your shadowing experience with us
- While observing in the gym, please keep cell phones silenced and put away.
- Questions for therapists are encouraged, but we ask that you save them until the end of the session
- Bring a packed lunch. However, please know that we have limited refrigerator space.
By signing this agreement, the student acknowledges their understanding of these expectations and their commitment to supporting a safe, respectful, and positive experience for Schreiber clients, families, staff, and volunteers
Applicant Signature
Parent/Guardian Signature (if applicant is under 18 years of age)
Date

MonthDayYear
Date

Waiver
In consideration of being allowed to participate as a shadow student at the Schreiber Center for Pediatric Development ("SCPD") and all related events and activities ("Event"), I, on behalf of myself and on behalf of my heirs, assignees, personal representatives and next of kin and intending to be legally bound, consent to the use of any photos, slides, film or sketches by SCPD taken during the Event for publicity, advertising, promotion or any other purpose in connection with SCPD's work, and further agree to release, indemnify and hold harmless SCPD and its officers, directors, officials, agents and employees, from any and all liability, for loss, harm, damage, injury, cost or expense whatsoever including without limitation, property damage, personal injury (including emotional distress), and/or death which may occur in connection with preparation for, or participation in, the Event, or participation in any Event- related activity, and for any claims or causes of action whatsoever, including, but not limited to, those based on publicity rights, defamation or invasion of privacy, to the fullest extent permitted by law. I agree that any claims or disputes arising from my participation in the Event shall be governed by the laws of the Commonwealth of Pennsylvania, without regard to its conflict of laws provisions, and the Court of Common Pleas of Lancaster County, Pennsylvania shall have exclusive jurisdiction and venue.

I HAVE READ THE FOREGOING WAIVER AND RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I understand that all information typed, read and/or heard pertaining to clients of the Schreiber Center for Pediatric Development is to be kept in strict confidence and not to be transmitted or discussed outside of the Schreiber Center.
Applicant Signature
Parent/Guardian Signature (if applicant is under 18 years of age)
Date

MonthDayYear
Date

HIPPA CONFIDENTIALITY AND PRIVACY PRACTICES ACKNOWLEGEMENT
I have read Policy 502-Notice of Privacy Practices and Policy 127-HIPAA Confidentiality and Security of Protected Health Information Compliance and have had an opportunity to have my questions answered regarding the Center's Confidentiality and Security of Protected Health Information policy. Confidential information, whether written, verbal, film, or electronic media, may be used or disclosed in a manner, which complies with these policies. I understand that I must comply with these policies and that failure to do so in any way will subject me to disciplinary action, up to and including termination of employment or opportunity to volunteer my services at the Center.
Applicant Signature
Parent/Guardian Signature (if applicant is under the age of 18 years old)
Date

MonthDayYear
Date

Non-Disclosure Statement Acknowledgement
I acknowledge that while shadowing at the Schreiber Center for Pediatric Development, I will act responsibly in the course of my duties solely in the best interests of the institution, in terms of non-disclosure of any HIPPA-protected or proprietary information. In addition, with regard to any inside information as to business activities of the institution or any of its members, I shall refrain from utilizing or sharing in any for such information for the benefit of myself, my immediate family, or any entity in which I may have a material, financial or other beneficial interest. This would include Schreiber's donor database information.
Applicant Signature
Parent/Guardian Signature (if applicant is under the age of 18 years old)
Date

MonthDayYear
Date
Should be Empty:

Schreiber: Student Shadow Application

Please Upload Required Clearances

Shadow Student Agreement

Waiver

HIPPA CONFIDENTIALITY AND PRIVACY PRACTICES ACKNOWLEGEMENT

Non-Disclosure Statement Acknowledgement