Internship Application Home Services Community Engagement Internship Program Please select your areas of interest (check all that apply). Environmental Health Services Bureau of Air Quality Control Lead-Based Paint Program Public Health Engineering Consumer Health Services Occupational Health Other… Enter other… Health and Clinic Services TB Control Family Planning / Maternity Dental Services HIV / STD Outreach and Screening Immunization Clinics Other… Enter other… Public Health Planning, Monitoring and Policy Development Epidemiology Staff Development and Training Process Improvements / Project Management Community Health Statistics Health Planning Public Health Practice Other… Enter other… Community Support Animal Regulation and Control Bureau of Vital Statistics Laboratory Services Women, Infants and Children (WIC) Program Area Agency on Aging Health Promotion and Education Multi-Service Centers Public Health Preparedness Other… Enter other… Support Services Human Resources Employee Wellness Information Technology Safety Other… Enter other… About You Applicant Contact Information Name Email Phone Address City/Town State/Province - 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None -ManWomanNon-binaryAgender/GenderlessAndrogyne/AndrogynousAporagenderBigenderDemi-agenderDemi-boyDemi-fluidDemi-girlDemi-genderDemi-non-binaryGenderqueerGenderfluxGenderfluidGender-indifferentGender-neutralGraygenderIntergenderMaveriqueMaxigenderMultigender/PolygenderNeutroisPangender/OmnigenderTrigenderTwo-spiritPrefer Not to AnswerOther… Enter other… Ethnicity Ethnicity - None -CaucasianLatino/HispanicMiddle EasternAfricanCaribbeanSouth AsianEast AsianMixedOther… Enter other… Your Availability Dates Available for Internship Begin Date End Date Hours Available for Internship Begin Time End Time Education Name of School / College / University Degree Program Field of Study Expected Graduation Date Faculty Sponsor Will you receive school credit for this internship? - Select -YesNo Sponsor Contact Information Faculty Sponsor Name Sponsor Email Sponsor Phone Emergency Contact Emergency Contact Emergency Contact Name Emergency Contact Email Emergency Contact Phone Please list two references. Please list two references. Faculty Reference Faculty Reference Name Faculty Reference Email Faculty Reference Phone Personal Reference (non-relative) Personal Reference Name (non-relative) Personal Reference Email Personal Reference Phone Upload Files Upload your resume or circulum vitae, and statement of interest. Resume / Curriculum Vitae One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Statement of Interest One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. More Information Please add any other relevant information. CAPTCHA This question tests whether you are a human visitor and prevents automated spam submissions. Leave this field blank Page last reviewed: September 26, 2022
