Internship/Field Experience Request Form - Northeast Health District

Your Name (First and Last Please)

Your Email Address please double check to be sure it is correct - we will use this to contact you

Phone Number

Field Experience Type

If other, please describe your request

School/Institution

If other school, please indicate what school this will be applied to... If not related to school, why are you looking to volunteer?

Program/Major

If other program, please describe your program of study...

Month and Year You Would START the Internship

Deadline for decision (or deadline to submit request to school)

Describe why you would like to complete your internship/field experience with the Northeast Health District.

Please indicate any specific programs or departments you would like to be considered for, or that you have a specific interest in.

Please list any training, education, skills, software experience or other background info that may help with placement or decision.

Availability - Please list the times you would be available for this internship/placement. (For example, Monday 9am-2pm, Tues-Thurs 1-4pm, Unavailable on Friday (Work), Saturday All day, etc)

Geographic Availability (Counties) - Our service area includes 10 counties around Athens. Please check the counties you are willing to travel to on a regular basis.

Other comments or information, including special needs or requirements.