First Name:

Last Name:

Current address:

City: State: ZIP code:

Home phone number: Cell phone number:

E-mail address:

Gender

Male

Female

Academic institution attending:

School/College of: (Example: College of Health Sciences)

Degree working on/program:

Year in program:
Junior
Senior

Graduate Student (Masters)

Doctoral

Other

Faculty advisor/University contact name:

Advisor e-mail address:

Advisor phone number:

Advisor street address:

City: State: ZIP code:

Is an internship, service learning experience, observation or rotation required for your degree?

Yes

No

Please select the type of learning experience for which you are applying:

Please choose from the list below Internship Service Learning Experience Observation/Rotation Residency Capstone Project

Number of hours required?

Anticipated starting date of internship/observation/rotation/service-learning experience (mm/dd/yyyy):

Anticipated ending date of internship/observation/rotation/service-learning experience (mm/dd/yyyy):

Program of interest (Please select at least one):

Accounting/Fiscal

Clinical Services

Community Health Planning

Diabetes

Disaster Preparedness
Early Childhood/Healthy Start

Environmental Health

Epidemiology/Communicable Diseases
Family Planning

Health Education/Promotion

Health Informatics/GIS

HIV Case Management

Home Visiting Services/HANDS

Human Resources
Immunizations
Leadership and Management

Nutrition Services
Oral Health

Public Information (Media, communications)

School Health Promotion

Support Services (Clerical, medical records)
Tobacco Education

Other:

I am interested in this opportunity because (i.e., what I hope to gain):

I am a great candidate for this opportunity because (i.e. knowledge, skills, experience):

Current degrees/licensures (mark "N/A" if none):

Please upload a file with your course description and required learning objectives here (*.doc files only please):

My resume is attached: Yes No

Attach resume file here (*.doc files only please):

Date application completed:

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