APPLICATION FOR THE MEDICAL SHADOWING COURSE - HOSPITAL PLACEMENT
This application should be submitted no later than one week before the beginning of the semester.

• Name*
  First Last
• Banner ID#*
  Please enter a number from 800000000 to 800999999.
• Please list your Major(s) and Minors(s).*
• Email*
  Enter Email Confirm Email
• Phone*
  Please use the following form: (###) ###-###
• Number of credits completed so far:*
  Please enter a number from 0 to 200.
• Number of credits in progress:*
  Please enter a number from 0 to 24.
• Estimated Graduation Date:*
  Please enter a number from 2018 to 2030.
• Semester and year that you wish to enroll in this course:*
• Name, address, and telephone number of the office, clinic, or center where you will be shadowing a medical professional:*
• Name of doctor/nurse/PA/professional who you will shadow:*
• Their contact telephone number:*
  Please use the following form: (###) ###-###
• Their contact email address:*
  Enter Email Confirm Email
• How many hours per week will you be working?*
  Please enter a number from 0 to 40.
• Please provide a description of likely tasks, responsibilities, and experiences.*
• What screening or tests are required for working in this location?*
• Are all screening and tests completed?*
  • YES
  • NO
• What are your professional goals after completing your NMSU undergraduate degree?*