About UsJoin UsStudent Learning Application Student Learning Application Student InformationName* First Last Current Address* City* State*ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYZip Code* Contact Phone Number*Email* Gender* Male Female Academic InformationAcademic Institution Attending* School/College of* Example: College of Health SciencesDegree working on/program* Year in Program*Junior in collegeSenior in collegeGraduate student (masters)DoctorateOtherOther Year in Program Faculty Advisor/University Contact InformationContact Name* Contact Phone*Contact Email* Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Is an internship, service learning experience, observation or rotation required for your degree?* Yes No Please select the type of learning experience for which you are applying.*Internship/practicumService learning experienceObservation/rotationResidencyCapstoneTotal number of hours required for the entire learning experience?*Anticipated start date:* MM slash DD slash YYYY Anticipated ending date:* MM slash DD slash YYYY Program of interest* Accounting/Fiscal Clinical Services Community Health Planning Disaster Preparedness Diabetes/Nutrition Environmental Health Epidemiology/Communicable Diseases Family Planning Health Education/Promotion Health Informatics/GIS HIV Case Management Human Resources Immunizations Leadership and Management Oral Health Public Information (Media, communications) Other Please select at least one. Program of interest other I am interested in this opportunity because (i.e., what I hope to gain):*I am a great candidate for this opportunity because (i.e. knowledge, skills, experience):*Current degrees/licensures (mark "N/A" if none):*Upload Resume*Accepted file types: doc, docx, pdf, Max. file size: 200 MB.Microsoft Word or PDF format onlySyllabus/College Document* Drop files here or Select files Accepted file types: doc, pdf, Max. file size: 200 MB, Max. files: 3. Please upload a syllabus or class/college documents describing your learning experience/preceptor needs.