Student Internship Application – General First Name * Last Name * Mobile Phone * Email Address * Student Physical Address Address 1 Address 2 State or Province Please Select…AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutD.C.DelawareFloridaMicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriMarianasMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyomingMilitary AmericasMilitary Europe/ME/CanadaMilitary PacificAlbertaManitobaBritish ColumbiaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory City Zip School Contact College / University City State or Province Please Select…AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutD.C.DelawareFloridaMicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriMarianasMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyomingMilitary AmericasMilitary Europe/ME/CanadaMilitary PacificAlbertaManitobaBritish ColumbiaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory Program or Area of Study List your school or program title (School of Nursing Medical Assistant). Enter your program of study’s EAA Code Is your program accredited? Blank Yes No First Name of Program Instructor Last Name of Program Instructor Phone Email Tell us about you Degree Level Certificate or DiplomaAssociate’s DegreeBachelor’s DegreeMaster’s DegreeDoctorate Degree Expected Graduation Date MM/YYYY What is your current GPA Do you currently work for Halifax Health? Blank Yes No If so, what is your employee ID number? Desired type of position/department placement Why should we consider you for placement at Halifax Health? Please limit your entry to 500 characters.Student Internship Desired start of Internship? mm/dd/yyyy Desired end of Internship? mm/dd/yyyy Who referred you to Halifax Health School AdvisorHalifax Health Team MemberPrior StudentWebsiteHalifax Health Office of Student Placement If applicable, provide the name of Halifax Health Team Member who you have had communications with:
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