Russell Sage College Dietetic Internship Application Release Form
Onsite and Remote Tracks 
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Applicant Name: *
Email: Please provide an email address for contact, if necessary, by the RSC DI Application Review Committee
 *
Dietetic Internship Program Type (select program type you are applying for, check all that apply):
 *
Required
Full-time or Part-time Preference:
 *
Required
REMOTE TRACK ONLY: State(s) where you will be completing your supervised practice hours: 
REMOTE TRACK ONLY NOTE:
Dietetic Internship Graduate Certificate and MS-DI Accelerated Applicants: All preceptors must be secured upon application to the program. The Preceptor Sign-up Form must be submitted with your DICAS application to be considered for the remote track. Please confirm you have submitted the sign-up form with the DICAS application
Clear selection

ONSITE TRACK ONLY: For location: Rank 1-4 (1=First Choice & 3 =Last Choice), or 0= unwilling to  go to this location

*Locations will be dependent on placement availability.

Release for placement: I understand that if I choose any of the areas listed below, I may be placed in any of those areas and I will be prepared to remain in the chosen area for the duration of supervised practice. 

I understand that if a placement cannot be secured in the area chosen (outside of the Capital District) a placement will be secured for me in the Capital District and may require a longer commute or temporary relocation at my own expense.

First Choice
Second Choice
Unwilling
Third Choice
Greater Capital District (Albany, Schenectady, Troy)
Saratoga Springs/Glens Falls
Hudson/Poughkeepsie
ONSITE TRACK ONLY: List any other locations not listed above you would be willing/prefer for placements.

*Locations depend on placement availability

Release for placement: I understand that if I list any of areas below, I may be placed in any of those areas and I will be prepared to remain in the chosen area for the duration of supervised practice. 

I understand that if a placement cannot be secured in the area chosen (outside of the Capital District) a placement will be secured for me in the Capital District and may require a longer commute or temporary relocation at my own expense.  
Application Payment: A check for $40.00 payable to Russell Sage College must be mailed to the address below. This fee is waived for current Russell Sage College students.

ATTN: Lisa L Schmitt, MS, RDN, CDN
Dietetic Internship Director
Nutrition Science Department
Russell Sage College
65 1st Street
Troy, NY 12180

Please enter the date that you mailed the check.
 *
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DD
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YYYY

Acknowledgement:

Release for Application File

I authorize my DICAS application to be released to individuals participating in the Russell Sage College  Dietetic Internship (RSC DI) selection process. I understand that the purpose of this review is for  selection purposes only and information contained in the file will be kept confidential by the reviewers. 

Acceptance Day Procedure: 

On Appointment Day, I will email stating my acceptance/declination of the appointed spot to Michelle Guy, DI Director, guym@sage.edu. 

I understand the implications of the application release, and the need to identify my preferred program status and placement for acceptance into the RSC MS-DI or DI Program. 

 *
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