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Home
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Education Services
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Healthcare Career Exploration
Healthcare Career Exploration
Students interested in career exploration should complete the application below. Once St. Anthony receives your application, you will receive an email with more information and next steps.
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ENT Ear/Nose/Throat (Otolaryngology)
Nephrology
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Pulmonology
Urology
All fields marked with
*
are required.
Please complete this application to be considered for a healthcare career exploration experience at St. Anthony.
Student Information
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip Code
*
Primary Phone Number
*
Email Address
*
Your Date of Birth
Emergency Contact (First and Last Name)
Emergency Contact Phone Number
Is this experience required of an academic program in which you are enrolled/ plan to enroll?
Yes
No
Educational Institution:
Current Major Field of Study:
Educational Level:
Anticipated Graduation Date:
What are the desired dates or time frame of the career exploration?
In which department/area are you interested in having your experience?
Have you already spoken with a specific staff person, or provider, about this request and if so, who?
What is the goal of your career exploration? What prompted your request?
Liability Release
I accept responsibility for liability for personal injury, loss or damage to me, or to my property, while I am participating in a student experience and I agree to sign a liability release waiver.
*
Yes
Attestation:
I recognize the importance of maintaining the confidentiality of patients and residents at St. Anthony Regional Hospital and Nursing Home, and of assuring their right to privacy. I pledge that I will not divulge any information about a patient or resident with persons in or out of the hospital or nursing home facilities unless the other party has a professional need to know.
*
Yes
By typing your full name, you attest to the validation of your application. Type Your Signature Here
*