CPH Internship Pre-Registration Form

SECTION I: Personal Information

First Name Required Question

Last Name

Street Address

Apt/Suite/Office

City

State

Postal Code

Email Address Required Question

Phone Number Required Question

Mobile Phone

A minimum of 23 CPH program credits must be completed before registering for the Public Health Internship Seminar Course.

Please enter the number of credits you expect to have successfully completed before registering for this course:
Required Question

SECTION II: Academic & Professional Information

Previous Education

	College/University	Degree Earned	Year	Major
1.
2.
3.

List any awards and/or honors

Related Work/Volunteer Experience

Organization/Location

Date

Tasks/Responsibilities

Organization/Location

Date

Tasks/Responsibilities

Organization/Location

Date

Tasks/Responsibilities

1. Language skills

	Mother tongue	Read	Write	Speak	Understand
Spanish
French
German
Chinese
Japanese
Italian
Other

If you speak a language that is not listed in the question above, please type what language it is below.

Computer skills

1.
2.
3.
4.
5.
6.

SECTION III: Internship Preferences

Internship Semester:

Internship Location

	NYC
	NY State
	Other US State
	International

Areas of interest. Mark all that apply in order of preference, with number 1 as your first preference.

Adolescent Health
Environmental Health
Health Policy
Health Promotion/Disease Prevention
HIV/AIDS
Humanitarian Assistance
Maternal & Child Health
Mental Health
Nutrition/Physical Activity
Other

This section should list possible internship sites in the order of your preference. Provide additional information such as skills needed for possible assignments or projects and time period for the internship (days and hours). The listed agencies should be shared with your academic advisor and discussed as you make a final decision.

Preference #1

Name of agency
Address
Person to contact at agency
Title
Phone
Possible experiences/projects
Possible experiences/projects

Preference #2

Name of agency
Address
Person to contact at agency
Title
Phone
Possible experiences/projects
Possible experiences/projects

Preference #3

Name of agency
Address
Person to contact at agency
Title
Phone
Possible experiences/projects
Possible experiences/projects

SECTION IV: Personal Statement

Use the space below to provide a statement of purpose (500 words minimum) which includes your goals/objectives for your MPH internship and the skills and experience you hope to gain. Required Question

Thank you for completing your internship pre-registration form. By clicking on the 'submit' button you are affirming that the information you have provided is true and correct.

Kindly type in your name in the box below. Required Question

	Fall	Spring	Summer
2007
2008
2009