Personal Information

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

Question Title

* 1. Name:

Question Title

* 2. Mailing Address:

Question Title

* 3. Phone & Email:

Question Title

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

Question Title

* 5. Is your parent/guardian an employee of Lake Region Healthcare or Prairie Ridge Hospital & Health Services?

Question Title

* 6. Do you have any physical disability needs?

Page1 / 5
 
20% of survey complete.

T