Fill Out the Physical Therapy Shadow Application

Physical Therapy Shadow Application Form

  • Date Format: MM slash DD slash YYYY
  • (Please indicate the current university you are attending. If you are not currently enrolled, please indicate either your most recently attended school or where you are planning to attend in the future.)
  • (Enter your current year in school. If you are not in school, please indicate the number of years of education you have completed.)
  • Do you need the hours for graduate school? Are you just interested in learning more about the profession?
    Please provide us with days and times that work best for your schedule. We generally schedule shadow opportunities for 4 hour blocks, though this can be adjusted on a case-by-case basis.
  • Covid-19 Vaccination Policy

    Due to COVID-19, and in our best efforts to do all we can to flatten the curve and follow safety guidelines set out by the CDC, Emerge is requiring vaccination against COVID-19 for all positions, paid and unpaid, who may be interfacing with clients. If you have personally chosen to not receive the COVID-19 vaccination, please let us know so that we can review the level of risk and implement additional measures to keep our clients, staff, and families safe. By affixing my signature below, I verify that I have read and will adhere to this vaccination policy.
  • Date Format: MM slash DD slash YYYY
  • Accepted file types: jpg, png, pdf.
  • Dress Code

    Since we are working with children of all ages in a professional setting, you are expected to dress in comfortable and appropriate business casual attire. Clothing that is revealing in any manner is unacceptable. Acceptable items to wear include: khakis, chinos, dark-wash jeans, black/navy solid scrubs with collared shirts, button downs, cardigan/sweaters, long-sleeved or short-sleeved tops. You may wear open or closed-toed shoes. Be prepared to remove your shoes as many of our treatment spaces have mat floors; shoes are not allowed on the matts. Dress code is considered “business casual.” Please do not wear: distressed jeans, yoga pants, shorts, skirts, shirts that expose midriffs or cleavage, dangling jewelry. Emerge is a scent and smoke free environment. Please refrain from perfume, scented lotion, or other strong scents. Also avoid any attire that contains reference to alcohol, tobacco, drugs, violence or inappropriate language is unacceptable. By affixing my signature below, I verify that I have read and will adhere to this dress code.
  • Date Format: MM slash DD slash YYYY
  • Statement of Confidentiality

    The employees, students, and volunteers of Emerge Pediatric Therapy are expected to adhere to a strict code of confidentiality. Clients are never to be discussed with persons outside of clinic staff, unless the parent has given explicit permission. If an oral release is given, a written release should be obtained as soon as possible, and maintained on file. Information about an individual child should never be discussed with another parent. Be aware that sound does travel easily within the office. Personal client information should only be discussed in private. If you need to have a detailed discussion with a parent, do not do it in the waiting room. Be cognizant of the child’s presence when giving feedback at the end of the session. Be aware that we live in a small community. If you recognize a client outside of the office do not talk to them unless they initiate conversation. Once conversation is initiated do not reference how you know them, unless they bring it up. By affixing my signature below, I verify that I have read and will adhere to this statement of confidentiality.
  • Date Format: MM slash DD slash YYYY
  • Statement of Professionalism

    Our first priority is always the quality of services provided to clients and families. While you observe the delivery of these services, it is expected that you maintain a high level of professional behavior. During your shadow shift, it is expected that you are strictly observing and that you are not interfering with any portion of the session activities, unless directly instructed to do so by your supervising therapist. Phones should be silenced and remain with your belongings. Phones may not be present in sessions. Your proximity to session activities may vary based on the client, and your supervising therapist will let you know what is preferred for any given client. When in doubt about what is expected, ask your supervising therapist. As a teaching facility, all therapists are happy to assist you. By affixing my signature below, I verify that I have read and will adhere to this statement of professionalism.
  • Date Format: MM slash DD slash YYYY