Student Shadow Application & Agreement Form

Social Pediatric Therapy welcomes students to apply for shadowing opportunities, complete the form below:

Name(Required)

First Last

Phone(Required)

Email(Required)

Current School/University

Year in School

Area(s) of Interest

Speech Therapy

Occupational Therapy

ABA Therapy

Check all that apply

Shadow Request Details

Preferred Dates

Preferred Days/Times

Total Hours Requested

Is shadowing required for a course or application?

Yes/No - If yes, please explain

Emergency Contact

Name

Relationship

Phone

Health & Safety(Required)

I confirm I am in good health and able to participate in light physical activity. I understand I may not attend if I am experiencing symptoms of illness.

Confidentiality Agreement(Required)

I agree to maintain strict confidentiality regarding all clients, families, and clinic information observed.

I understand that taking photos, videos, or sharing information on social media is strictly prohibited. I understand that any breach of confidentiality will result in immediate termination of my shadow experience.

Professional Expectations(Required)

I agree to follow the clinic dress code

I understand that I am observing only and may not provide direct treatment or advice. I agree to arrive on time and communicate promptly if I need to cancel.

Liability Waiver

I understand participation may involve light physical activity and inherent risk. I release the clinic and its staff from liability related to my observation experience.

Student Signature(Required)

First Last

Date Signed(Required)

Parent/Guardian Signature (if under 18)

First Last

Student Shadow Application & Agreement Form

Shadow Request Details

Emergency Contact

Liability Waiver

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