Name

Address

Street Address

Street Address 2

City

State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

General Information

Phone Number

Email

School/College

School Contact Person and Title

School Contact Phone Number

School Contact Email

Will your internship be

• Clinical
• Non-clinical

Type of internship

• Clinical
• Community Health
• Dietetic

When is your start date?

End date?

How many hours per week?

Times that you are available during the week?

Total number of internship/volunteer hours required?

What are the requirements for your internship? (ie: a project, a paper, specific skills taught, etc.)

Interview Questions

What is your area of study?

What classes/courses are you currently taking?

Please list any pertinent work experience

What is your current knowledge of Public Health and its services?

Why have you chosen Public Health for your internship/volunteer experience?

What skills do you possess that would make your time more productive (i.e., computer skills, etc)?

What do you hope to learn during your field experience at the health department?

Submit