Shadowing Request – Family Medicine (Outpatient, Community Medical Groups)
Name
Last Name
Preferred Pronouns
Phone Number
Personal Email
School Email
Have you graduated high school or earned your GED?
Yes
No
School
School Instructor Name
School Instructor Email
Area of Study
Please select...
Medical Assistant (Clinical)
Other (Shadowing)
If other, please specify
Are you a Penn State Health Employee
Please select...
Yes
No
Number of Hours Requested
Requested Start Date
Requested End Date
If you have specific requests, please complete below:
If other, please specify:
Practice Site:
Preceptor:
City:
Specialty:
Describe your request or add additional comments:
Would you like to be contacted by Penn State Health for job opportunities?
Yes
No
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