Registration Form

Job Shadowing Program Participant Registration

Have you previously participated in Windsor Regional Hospital’s Take a Walk in My Shoes Program?
 
Are you currently an employee of Windsor Regional Hospital?
 
 
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Area of Job Shadowing

Please indicate your preferred Area for Job Shadowing: (i.e. Nurse, Diagnostic Imaging, Laboratory, Health Records, Pharmacist, Social Work, Finance, Environmental Services, CSR, Administration, Human Resources, Occupational Therapy, Physiotherapy, etc.)

Specific Area:

If applicable please include the specific area of interest within the discipline you wish to shadow. For example, if Nursing – OB, Paeds, Rehab, Long Term Care or Social Work – Children, Mental Health, Adults.

 

Emergency Contact Information:

 
 
 
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Confidentiality:

I agree that during my job shadowing experience and afterwards, I will not directly or indirectly disclose or use any confidential information including but not limited to information about patients or the organization.
 

Media Release:

I hereby grant to Windsor Regional Hospital and his/her legal representatives the right to use and publish video recordings or pictures of me, or in which I may be included in any Windsor Regional Hospital publications or broadcasts.
 
For those under 18 years of age:
I have read through the program materials and agree for my son or daughter to participate in the Take a Walk in My Shoes program at Windsor Regional Hospital.

 
 

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