Application for Student Internship

APPLICATION FOR STUDENT INTERNSHIP

NAME ______TODAY’S DATE ______

(Last)(First)(M.I.)

ADDRESS ______

(Street)(City)(State)(Zip)

PHONE ______SS#______

EMAIL ______

Are you at least 18 years old? YES ___NO ___

Are you a previous applicant? YES ___NO ___If yes, when did you apply? ______

In emergency, contact ______

(Name)(Address)(Phone)

EDUCATION

HIGH SCHOOL ______

(Name & Address)

______

(City)(State) (Zip)(Phone)

Graduation Date ______Diploma ____ or GED ____

COLLEGE/UNIVERSITY______

(Name & Address)

______

(City)(State) (Zip)(Phone)

Graduation Date ______Degree: Associate ____ Bachelor ____ Master ____

OTHER SCHOOLING______

(Name & Address)

______

(City)(State) (Zip)(Phone)

Completion Date ______Degree or Certificate Awarded: ______

MILITARY SERVICE: Branch ______Rank ______Discharge Date ______

REFERENCES

On a separate sheet of paper, TYPE the names, email address, and phone numbers of three (3) different people familiar with your abilities. Incomplete information may reflect negatively on your application. Do NOT include relatives. One reference should include a professor in your college program. Your reference may be contacted by a program official. Do NOT include letters of recommendation with your application materials.

EMPLOYMENT

Are you presently employed? YES ___ NO ___If yes, your job title: ______

Name of Employer: ______Phone: ______

Employer Address: ______

Supervisor Name: ______May we contact? YES __ NO __

GENERAL INFORMATION

1. Have you ever been employed in healthcare or fitness? YES ___ NO ___

If yes, your job title: ______Name of facility: ______

How long? ____years ____months

1. Have you ever volunteered in healthcare or fitness? YES ___ NO ___

If yes, did you interact with patients/members: YES ___ NO ___

Name of facility: ______How long? ____hours (approximate)

1. Do you have a relative employed in healthcare or fitness? YES ___ NO ___

Relationship to you? ______Name of facility: ______

1. Have you ever been dismissed, suspended, or placed on probation from any school or job?YES ___ NO ___ If yes, please explain on a separate sheet of paper.

1. Have you ever been convicted of a misdemeanor or felony? YES ___ NO ___

NOTE: convictions or charges resulting in any of the following must also be reported: plea of guilty, plea of no contest, withheld or deferred adjudication, suspended or stay of sentence, military court martial.

SUBMISSION OF APPLICATION

Please submit your OFFICIAL grade transcripts from high school and all post-secondary education. Also submit a cover letter describing yourself, a current resume, any personal background that is relevant, and why you wish to be in the healthcare or fitness industry. Omission of any required items will be just cause for rejection of the application without contact. Your application is dependent upon submission of the required material, successful completion of all other requirements and interviews, and submission of the required health and physical forms (after being selected). Selection will not be discriminatory with respect to race, color, creed, sex, age, disability, national origin, or any other protected class.

To the best of my knowledge, the information given is truthful and complete. I understand that I may be refused acceptance or be dismissed from the program after acceptance if any of the information submitted is false or misleading.

______

Signature of ApplicantDate