1 Directions: Please complete the ENTIRE application form before submitting. Incomplete or handwritten applications will be automatically returned to the student unless prior arrangements have been made. STUDENT INFORMATION Name: __________________________________________________________________________________ Concentration: _____________________________________________________________________ UFID: ______________________________________ Mailing Address during Internship: ______________________________________________________________________________________________________________________ Street Apt. # City State Zip Phone # ___________________________ Email: _____________________________________________ Permanent Address ________________________________________________________________________________________ INTERNSHIP INFORMATION Course: PHC 6946_______ Course Credits: _______________________________________ Semester/Year Desired: _________________ Final Report Due Date: ___Public Health Day___________ Project Title: ______________________________________________________________________________ My internship is located in a rural area YES NO My internship impacts rural populations(s) YES NO Do you have reliable transportation? YES NO Do you have any disabilities that might hinder your performance during your project? YES NO If yes, please explain _______________________________________________________________________ Does this site require a formal contract to be signed prior to beginning internship? YES NO Are you required to have insurance as result of participation in this project? YES NO If YES, please check all that apply: Internship and Special Project Proposal University of Florida Mater of Public Health Program
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internship and special project proposal revised 2.7users.phhp.ufl.edu/prycefegumpss/internship and special project... · Internship: The work plan must provide sufficient information
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Address:_________________________________________________________________________________________________________________Street Suite/Room# City State Zip