Community Health Initiative (CHI) Internship Application (Organization Form)
INCOMPLETE APPLICATIONS AND THOSE ORGANIZATIONS NOT MEETING THE PROGRAM REQUIREMENTS WILL NOT BE CONSIDERED. FOR MORE INFORMATION, PLEASE GO TO THE CHI WEBSITE:
https://diversity.umn.edu/bced/node/82
* Required
General Information
Organization Type
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Nonprofit
Business
Organization Name
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Your answer
Contact Person Name & Title
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Your answer
Executive Director or Business Owner(s)
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Your answer
Street Address (including Suite or Room #)
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Your answer
City
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Your answer
State
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Your answer
Zip Code
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Your answer
Phone
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Your answer
Fax
Your answer
E-mail
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Your answer
Web Page
Your answer
Year Established
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Your answer
Number of Full-Time Employees
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Your answer
Number of Part-Time Employees
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Your answer
Organization Description
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Your answer
Community Internships are available in the following areas. Please check the topical area(s) for which you are requesting a summer intern.
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DO NOT CHECK MORE THAN TWO CATEGORIES
Public Health
Community Health Education
Social Work
Population Health Coordination
Nursing Care/Management
Health/Medical Research
Feasibility Study
Program Evaluation/Measurement
Program Development
Community Outreach
Communications/Event Planning
Other:
Required
If you are interested in working with a particular student, please provide their name and e-mail address. (NOTE: the Student must also apply and request you for their Internship Organization.)
Your answer
Internships can be full-time (40 hrs/wk), 3/4 -time (30 hrs/wk) or part-time (20 hrs/wk) Please indicate your preference.
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NOTE: Total number of hours below are based on a 12-week timeframe over the course of the summer.
Full-time (480 hours)
3/4-time (360 hours)
Part-time (240 hours)
No Preference
Required
List Internship Goals & Objectives:
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Describe your Community Internship in DETAIL. Please be SPECIFIC when describing the scope of this request. Describe how the results of this internship will benefit health disparities and the community at large as well as the organization. What valued experiences will the student gain by participating in this internship?
Your answer
List Internship Tasks & Timelines:
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Your answer
List Internship Outcomes & Deliverables:
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Your answer
Please list any specific skills, knowledge or past experiences the student should have to be successful with this internship.
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Your answer
Please share any other information about your organization that would be useful in considering your application.
Your answer
How did you hear about our program? (Check all that apply)
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BCED Website
CHI E-mail Notice
Brochure/Mailing
E-mail notice from another organization (please name)
Referral from another organization (please name)
Other:
Required
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