WellSpan Surgery & Rehabilitation Hospital Shadowing Program Application

55 Monument Road - York, PA 17403 - (717) 812-6163

Areas marked with ! must be completed.

Application

Full Name !

Address

Address 2

City

State

Zip Code

Phone

Email Address !

Verify Email Address !

Emergency Contact Name

Emergency Contact Phone

High School Student Only (grades 11 & 12)

Counselor Contact Name

Counselor Phone

Counselor Email Address

Comment on your education / and future health care goals.

What area or specialty are you interested in? !

Please explain your interest

What days and times would you prefer to observe?

Verification Text !

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