NCHD Internship Request Form
Use this form to request a practicum, internship or other field experience with the North Central Health District. While not all questions are required, the more information we have the better we will be able to work with you. Not all requests can be honored, as staff and projects change over time.

Important Notice: We currently cannot accept medical assistant, lab technician, or nurse practitioner students, due to staffing.

Name *
Your answer
Email Address *
Your answer
Phone *
Your answer
Address *
Your answer
What degree level will this field experience be applied to? *
For other degrees, or if it is not directly related to a degree, please choose "Other" and explain. Do NOT fill out this form if you are a nursing student.
If you are a graduate student, please list what field your undergraduate degree(s) are in
Your answer
School/College *
Current Degree Program/Department/Concentration *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms