Application for Mentor Program

HILLSIDE VETERINARY CLINIC David M. Dubusky, D.V.M. Loving, Expert Care 1475 Yauger Road Mount Vernon, Ohio 43050 Telephone: (740)392-6891 Fax: (740)392-2145

MENTORSHIP APPLICATION

Applicant Name:______Age ______

Address:______

Phone Numbers:______

Year in school:______School:______

Dates requested for Mentor experience:______

Are you a client of Hillside Veterinary Clinic? Yes______No______

Is the mentoring experience associated with a school requirement? Yes______No ______If yes, what is the class title? ______Instructors Name ______Instructors Phone Number ______

What is the learning objective of the class assignment? ______

Describe why an experience at Hillside Veterinary Clinic would complete the above learning objective: ______

Do you have an interest in a future career in veterinary medicine or an associated animal industry? Yes ______No ______if yes or maybe, describe your thoughts on future plans. ______Parent or Guardian Name ______Address ______

Phone Number where Parent/Guardian can be reached during the time the applicant is at the Clinic ______

Can you come to pickup the applicant during the day should a problem arise? ______If no, then please provide a contact person who will be able to pick up the applicant should the need arise. Contact person name ______Phone Number:______

Hillside's Expectations of Participants: Thank you for inquiring about the mentorship program at Hillside Veterinary Clinic. We provide the opportunity to mentor doctors and technicians on a limited basis. Students must be in the 9th grade or beyond and show an interest in an animal related career. Individuals are invited to spend a partial or full day at the clinic depending on the scheduled workload for that day.

Unfortunately, we are unable to accommodate all requests for mentoring. Applicants should fully complete this form and return it to Hillside Veterinary Clinic. We will inform you within one week as to whether or not a mentorship experience can be arranged. We value the days we are able to share with mentors however it is important to realize our primary mission is the health care of our patients and service to our clients.

1. Dress Code - We work in a professional business environment and the appearance of the doctors and staff is important. The same standard applies to mentoring individuals. Males should wear slacks (khaki or similar), a collared shirt and tie, and sturdy clean shoes. The clinic will provide a lab coat or smock. Females should wear slacks and tops with a professional appearance. A lab coat or smock will also be provided. We do not allow jeans, worn clothing, open toed shoes, dirty shoes, hats, gaudy jewelry, midriff shirts, or low cut shirts. Gum chewing, inappropriate language, and a disinterested attitude will be reasons to ask the student to go home early. 2. Learning – We expect you to learn. Ask questions about what you observe. The appropriate time for questions is outside the exam room. Do not interrupt the doctor and client. 3. Participation - The level of participation is dictated by the competency of the student. We routinely have students help hold animals, teach them techniques for medical care, and even scrub in for surgery. 4. Time: Be on time to start the day and have your ride at the end of the day be on time. 5. Lunch - Very flexible. The doctors generally do not take lunch or eat during intervals between cases. You can schedule a time for yourself to leave for lunch or bring a sack lunch to eat at the clinic. 6. Confidentiality - The medical and surgical information about patients and clients is to be kept confidential. 7. We do not accept more than one student per day. I, ______accept the above expectations for a mentor experience at Hillside Veterinary Clinic. I understand that working with animals in a hospital environment may pose certain uncontrollable risks of injury to the animals and myself. I will not hold Hillside Veterinary Clinic liable for any injury, which may be incurred, to my property or myself.

Applicant Signature: ______Date: ______

Parent/Guardian Signature: ______Date: ______