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Student Community Internship Application

PLEASE COMPLETE ALL INFORMATION

Contact Information
Name   
Address   
City   
State   
ZIP Code   
Home Phone   
Cell Phone   
E-mail Address
Student ID Number   
Anticipated Graduation Date   
Degree   
Major area(s) of study   
What U of MN School are you enrolled? Public Health
Social Work
Medicine
What is your student status? Full Time Part Time
Are you employed by the University of Minnesota? Yes No
If so, how many hours a week do you work?
Are you a U.S. Citizen or permanent resident? Yes No
Are you allowed to work on campus? Yes No
What type of visa do you have and when does it expire?

Type:

Expiration Date:
Do you have a car? Yes No
If you are interested in working with a particular organization or business, please provide the name, phone number, contact person and e-mail address.

Organization or Business Name:

Phone Number:

Contact Person :

E-mail Address :
Please complete information below.
Please check the types of projects in which you have EXPERTISE and SKILLS in:
Public Health
Community Health Education
Social Work
Population Health Coordination
Nursing Care/Management
Health/Medical Research

Feasibility Study
Program Evaluation/Measurement
Other

Please specify:

Please share any other information about yourself, your experiences or your studies that would be useful in considering your application.

It is expected that the student will spend approximately two to three months throughout the summer on this internship and will be under the supervision of the sponsoring organization.

Please list any scheduled events that may affect your participation (for example, if you are unable to work the internship before or after a certain date, or if you will be taking an extended trip).
Please PRINT a copy for your records before clicking the Submit button.
 
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Last modified on August 7, 2008