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...

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.