Request for Undergraduate Internship
Name of Applicant
First Name
Last Name
School Email Address
example@example.com
Secondary Email Address
example@example.com
Phone Number of Applicant
Please enter a valid phone number.
Name of School Or Institution
Title of School/Course for Internship
Name of Professor/Instructor of Course
Professor/Instructor Email Address
example@example.com
Anticipated Start Date of Experience
-
Month
-
Day
Year
Date
Hours of Availability (Monday-Friday)
Target Number of Hours Gained Per Week
Total Hours Needed for Course Credit
Preferred Clinic Locations and/or Cities (CA Only)
Are You At Least 18 Years of Age?
Yes
No
Goal for Experience
Is there an existing learning agreement/affiliation between your school and Spine & Sport?
Yes
No
Unsure
Submit
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