NCHD Nursing Student 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. Once your request is complete, please email your resume to
tiffany.borel@dph.ga.gov.

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
ACADEMIC INFORMATION
Please attach a copy of the course requirements for this practicum or summarize the goals here.
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. At this time we are unable to accommodate Nurse Practitioner (NP) Students.
School/College *
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