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Personal Information

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

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* 1. Name:

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* 2. Mailing Address:

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* 3. Phone & Email:

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

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

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* 6. Do you have any physical disability needs?

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