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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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?

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. *

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. *

By typing your full name, you attest to the validation of your application. Type Your Signature Here *