Internship Application

Applicant Information
Name:
Email- Address:
Phone:
Mailing Address:
Internship Applying To:
Hours Required:
Academic Information
School/College Information:
Major/Program
Available Date

-

Month

-

Day

Year
Start Time

:

Hour

Minutes
End Time

:

Hour

Minutes
Specify Type of Applied Learning Experience (internship, practicum, or other)
Criteria you would like the Health Department to cover:
Additional Information: