High School Student Internship Application

Applicant Information:

Full Name:

Phone Number:

Email Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Are you 15 years of age or older?

Yes

Do you have reliable transportation to and from the clinic?

Yes

School Information:

High School:

Program Title:

Expected Internship Dates (MM-DD-YY - MM-DD-YY):

Completing internship for credit?

Yes

Number of clinical hours needed:

Desired schedule:

Submit CV or Resume:

One file only.
100 MB limit.
Allowed types: pdf, doc, docx, jpg, jpeg, png.

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