Internship Applicant Registration Form

Intern Application

Fill out the form to be considered for Unpaid internships with the Dearborn County Health Department
Applicant Name*

First NameMiddle Name/sSurname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant E-mail*
example@example.com
Applicant Mobile Number*
Birth Date*

MonthDayYear
Do you have a valid drivers license?*
University/College Name
Major/Field of Study
Current Year (e.g., Sophomore, Junior)
Available start date*

MonthDayYear
Date
Available End Date*

MonthDayYear
Date
Please check off the Division you are most interested in*

NursingVital RecordsTobacco ControlFood (Inspections, safe food handling)Environmental (Septic)Health EducationHealth Department AdministrationEmergency PreparednessCommunity Outreach
Total Number of hours requested per week (Remember this is an unpaid internship)*
My Availability on Monday is   Time*   to   Time      Unavailable
My Availability on Tuesday is  Time*   to    Time   Unavailable
My Availability on Wednesday is   Time*   to   Time      Unavailable
My Availability on Thursday is   Time*   to   Time      Unavailable
My Availability on Friday is   Time*   to   Time      Unavailable
My Availability on Saturday is   Time*      to   Time      Unavailable
My Availability on Sunday is   Time*   to   Time      Unavailable
Please provide a brief statement on why you want to intern with the Health Department and what you hope to gain from the experience*
Please upload your resume & Cover letter*

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Please upload a document with three references including Name, Relationship, phone number and email address*

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Intern Application