Personal Information

Please complete this questionairre to request a job shadowing opportunity at Lake Region Healthcare. 

* 1. Name:

* 2. Mailing Address:

* 3. Phone & Email:

* 4. For minor applicants only, name of your your parent/guardian:

* 5. Is your parent/guardian an employee of Lake Region Healthcare?

* 6. Do you have any physical disability needs?

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