Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Page 1: Application Type

Shadowing experiences help learners explore healthcare careers at Children’s Nebraska. Choose the option that best matches your age group so we can guide you through the correct application steps.

Which age category applies to you?

Teen shadow learner (ages 17–18)Adult shadow learner (ages 19+)

Page 2: About You

Please provide your contact information so we can reach you about your shadowing request.

First Name

Middle Initial

Last Name

Date of Birth

Enter your date of birth (MM/DD/YYYY)

Email Address

Phone Number

Address

Street Address

Street Address Line 2

City

State

ZIP code

Have you ever been charged or convicted of a felony or misdemeanor, excluding parking or minor traffic violations?

YesNo

Page 3: Education Information

Please share your education information below.

Are you a current high school or college student?

YesNo

School Name

Grade Level or Degree Program

Page 4: Emergency Contact

Please provide the contact information for someone we can reach in case of an emergency.

First Name

Last Name

Emergency Contact Relationship

Phone Number

Page 5: Past Experience

These questions help us understand your past experiences with Children’s Nebraska, if any.

Have you volunteered at Children’s Nebraska before?

YesNo

Have you participated in a learning experience at Children’s Nebraska before?

YesNo

Have you previously worked at Children’s Nebraska?

Yes, I currently work hereYes, I have worked here in the pastNo

Please briefly describe your volunteer, learning or work experience at Children's Nebraska.

Page 6: Shadowing Details

Tell us more about the shadowing experience you’re interested in so we can try to find the best match for you.

Which health profession or area are you interested in shadowing?

We will make every effort to accommodate your request, but a specific placement cannot be guaranteed.

Have you already been in contact with someone at Children’s Nebraska regarding this shadowing or learning experience?

YesNo

Who have you spoken with?

Name and role, if known.

Preferred Dates and Times

First preferred date and time

List dates and times (e.g., June 10–14, mornings).

Second preferred date and time

List dates and times (e.g., June 10–14, mornings).

Third preferred date and time

List dates and times (e.g., June 10–14, mornings).

Preferred City Location

Please indicate number of hours needed to complete shadow experience

What do you hope to gain through a shadow experience?

Additional Comments

Page 7: Required Documents

To complete your application, please upload documentation that meets the requirements below.

MMR (Measles, Mumps, Rubella): Two valid vaccination dates OR a positive titer.
Varicella (Chicken Pox): Two valid vaccination dates OR a positive titer.
Hepatitis B: Three valid vaccination dates AND positive titer; OR a positive titer alone.
TDAP (Tetanus): Documentation within the past 10 years.
Influenza: Documentation of annual vaccine during the current flu season.
Tuberculosis Baseline Screening (before assignment) we will accept any one of the following:
- Blood test: Negative Quantiferon gold (QFT) – no older than one year from start date.
- Blood test: Negative T-spot – no older than one year from start date,
- Skin test: Two valid TST (typically both within the current year).
- For Past Positive: Proof of treatment plan and a current health questionnaire filled out within six weeks of Children’s start date.
Tuberculosis Annual Screening (if applicable) – completion of the TB Risk Assessment and Symptom Review form.
Any other medical screenings or immunizations required at the time of registration.

Immunization record

PDF or image files are accepted.

Page 8: Acknowledgments

Confidentiality Agreement

I understand that any information that I may obtain directly or indirectly concerning patients, families, visitors, staff, Children's Nebraska or affiliates will be held absolutely confidential. If I break confidentiality of patients and/or families I may be terminated from the shadow program.

Education Review

I understand that I am responsible to complete the education review of hospital and service area information.

I have read the above statements. I understand the written information and confirm that I have read and understood the above statements and agree to abide by the rules, regulations and policies of Children's Nebraska, affiliates, and the Office of Education. I understand that if I do not abide by rules, regulations and policies I may be terminated from the shadow program.

Parent / Guardian Consent

Electronic Signature

Typing your name below serves as your electronic signature and confirms that you have read and understand the acknowledgments above and give consent for your child to participate.

Parent or Guardian Full Name

Parent or Guardian Email Address

Parent or Guardian Phone Number

Save my progress and resume later | Resume a previously saved form