Intent to Intern Form

Submit this form no later than the semester PRIOR to interning

Name Name * First Last
Date Date * / MM / DD YYYY
School Address School Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home or Permanent Address Home or Permanent Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number: *
Email *
E Number *
Year in School *
Major/Option *
Semester of Internship *

Enter Fall, Spring or Summer and the year
Semester of Expected Graduation *
Number of Internship Credit Hours needed *

8 is required (320 clock hours) for Health Administration or Public Health
3 for Health Sciences
All pre requisites will be completed prior to semester of internship (PUBH 3700 and 4250, portfolio submission). *

All pre requisites will be completed prior to semester of internship (PUBH 3700 and 4250, portfolio submission). Yes No- and I am a Health Administration or Public Health Major No- and I am a Health Sciences Major
Geographic area where you would like to intern: *

Geographic area where you would like to intern: Charleston Area Home town area (specify below) Other US area (specify below) Abroad
If you do not plan to intern in the Charleston area, share where you would like to intern and why?
Which of the following settings are you interested in doing an internship? Check all that may apply: *

Which of the following settings are you interested in doing an internship? Check all that may apply: University or Community College (i.e. wellness programs, health education resource centers) Medical Care Institution/Hospital/Home Health Agency (i.e. Health Promotion Department, Community Education, Senior Health, Wellness Program) Voluntary organizations (i.e. American Red Cross, American Lung Association) Worksite (Employee Health Promotion Programs) Rehabilitation Centers/Nursing & Retirement Homes Professional associations (i.e. American School Health Association, American Public Health Association) Governmental agencies (i.e. CDC, National Institutes of Health, Area Agency on Aging) Public Health Departments (i.e. Illinois Department of Public Health, Coles County Health Department) Environmental agencies (i.e. Environmental Protection Agency, county health department environmental health division) Other - specify below
Other settings:
Have you met with your advisor to discuss the internship as part of your program plan? *

Have you met with your advisor to discuss the internship as part of your program plan? Yes No - if no, do not submit this form until you have.
Read the following statements. You must check each statement indicating you have read and understand it. *

Read the following statements. You must check each statement indicating you have read and understand it. I understand the internship probably will not be a paid internship I understand I must have blocks of time available to commit to the internship and therefore may not be able to take other classes during the internship experience. I understand the deadlines for arranging an internship: December 1 for Spring Semester Internships; April 1 for Summer Semester Internships; August 1 for Fall Internships