Job Shadow Interest Form

If you are interested in pursuing a Job Shadow, Internship, or completing a Student Practicum with Regional Health Services of Howard County, please submit your application and your information will be sent to the department you are interested in working with for further review. Availability is not guaranteed.

"*" indicates required fields

Please identify education level.*

High School Student

High School Graduate

College Student

College Graduate

High School Application

First Name*

Last Name*

Email Address

Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Please list what school you are attending.*

What year are you in school?*

Which department are you interested in for your job shadow?*

Is there a specific job within the department you are interested in? If so, please list it below*

Example: physical therapy, OB nurse, phlebotomist)

When would you like to complete your job shadow?*

How many days or hours do you need for your experience?*

College Student Application

First Name*

Last Name*

Email Address

Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code

What school do you attend?*

What year are you in school?*

What degree are you pursuing?*

If you are not currently enrolled in a college program, please provide an explanation for your request.*

What department are you interested in?*

Is there a specialty or specific job you would like to see?*

(Example MD, NP, women’s health, physical therapist, rad tech, MLT, RN)

What you are interested in pursuing within RHSHC?*

Job Shadow

Internship (No school affiliation)

Student Practicum (School affiliated)

How many hours are you requesting?*

What is your anticipated start date?*

When do your hours need to be completed by?*

What other information would be useful when determining appropriate placement?*

Danielle Wadsworth, APRN, CNM

Christopher Adams, MD

Henry Diggelmann, MD

Richard Rattay, MD

Seth Robinson, LMSW

Samantha Beck, FNP-C, ARNP

Mary Anderson, ARNP

Haley O’Donnell, CNM, APRN

Nicole Quandahl, ARNP

Bethany Sage, PMHNP

Matt Homstad, LMHC

Keenan Laraway, MD

Shawn Blake, CRNA

Samantha Bohr, CRNA

Kimberlee Burckart, MD

Danielle Courtney, ARNP

Jessica Jade Dutka, ARNP

Jessica Hart, ARNP-DNP

Dee Hosek, LMHC

Jessica Johnson, ARNP

Jon D Kammerer, MD

Jon David Maher, MD

Mandy Powers, ARNP

Chad Rasmussen, MS, APRN, CNP

Stephanie Riley, CNM, APRN

Todd Schissel, CRNA

Staci Ann Vrzak, ARNP

Laura Zielinski, LISW

Jeremy Waldo, ARNP

Brittanee Samuelson, MD

Job Shadow Interest Form