About UsJoin UsStudent Learning Application Student Learning Application Student InformationName* First Last Current Address*City*State*ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYZip Code*Contact Phone Number*Email* Gender*MaleFemaleAcademic 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 ProgramFaculty 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?*YesNoPlease 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:* Date Format: MM slash DD slash YYYY Anticipated ending date:* Date Format: 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 otherI 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.Microsoft Word or PDF format onlySyllabus/College Document* Drop files here or Accepted file types: doc, pdf. Please upload a syllabus or class/college documents describing your learning experience/preceptor needs.