NCHD Internship Request Form

NCHD Internship Request Form

Use this form to request an internship with North Central Health District. While not all questions are required, the more information we have the better we will be able to work with you. Not all requests can be honored, as staff and projects change over time. If you have any questions or concerns, regarding internship program for North Central Health District, please see the information below to contact the Internship Coordinator at patrice.lagroon@dph.ga.gov
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Academic Information
Please summarize the course requirements/goals here.*
What degree level will this field experience to be applied for? For other degrees, please choose "other".*

Undergraduate (BS, BA, etc.)Master's Degree (MPH, MS, MA, MEd, etc.)Doctorate (PhD, DrPH, EdD, etc.)Other
School/College*

Field Experience Information
How many hours are required? This is the total # of hours required over the entire length of the internship, NOT the hours per day or week.*
What semester/year are you looking for field experience? (Ex. Summer 2023, Fall 2024)*
Proposed start date and end date for field experience. When would you like to start your field experience? Actual start date may change, this just gives us an idea of when you would be available.*

MonthDayYear
Date
Comments/Additional Information: Enter any additional information or clarify any answers from above

Availability

Please list your time availability during your internship to indicate your availability for your field experience. Please keep in mind, most offices are open Monday - Friday from 8 a.m. - 5 p.m. We require all students to be available during specific times listed. We require all students to be available a minimum of 10 hours a week.
Monday*
Tuesday*
Wednesday*
Thursday*
Friday*
Weekends*
Is there any other information that you would like us to know? List any special needs, requirements, or accommodations that may be needed.

Please upload your resume here:*

Cancelof
If you have any trouble attaching your resume to your submission, please email a copy to patrice.lagroon@dph.ga.gov.
Should be Empty:

Academic Information