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2. Last Name*
3. First Name*
4. Email Address*
5. Phone Number*
7. Address*
9. College/University Name*
10. University Address*
12. Internship Coordinator's Name*
13. Internship Coordinator's Email Address*
15. Semester Applying for Internship*

    1. Fall

    1. Spring

    1. Summer
16. Date You are Available to Begin*
    Date You are Available to Begin
18. Current Educational Program*

    1. Bachelor's

    1. Master's

    1. PhD

    1. Other
20. Field of Study*
21. Expected Date of Graduation*
23. Are you seeking course credit for your internship experience?*

    1. Yes*
    2. No
24. *If Yes, number of hours required to fulfill requirement:
26. Does your program require preceptors to have specific credentials or years of experience?*

    1. Yes*
    2. No
27. *If Yes, what credentials/experience are required?
29. If selected, what would your work availability be during the internship?
31. Monday

    1. Morning
    2. Afternoon
32. Tuesday

    1. Morning
    2. Afternoon
33. Wednesday

    1. Morning
    2. Afternoon
34. What format of work are you interested in?*

    1. In Person
    2. Remote
    3. Hybrid
36. Thursday

    1. Morning
    2. Afternoon
37. Friday

    1. Morning
    2. Afternoon
39. Do you have a specific project that you would like to work on?*

    1. Yes*
    2. No
40. *If Yes, please describe the project:
42. Please identify all your areas of interest:*

    1. Biostatistics & Informatics
    2. Community Health
    3. Chronic Disease
    4. Emergency Preparedness

    1. Environmental Health
    2. Epidemiology
    3. Health Administration

    1. Health Education
    2. Health Policy & Management
    3. Infectious Disease

    1. Public Health Nursing
    2. Maternal Child Health
    3. Vaccination Programs
44. Please describe any relevant coursework or experience you have that would be beneficial to a potential internship position.*
46. Why are you interested in completing an internship with the Berrien County Health Department?*
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