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First Name:
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LastName:
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Student_ID:
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Date:
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Department/Program:
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School Address:
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Permanent_Address:
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School Phone:
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Permanent_Phone:
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Number of Hours completed prior to
internship:
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Overall GPA:
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GPA in required Courses:
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Number of Hours completed concurrently
with internship:
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Session in which you want to do your
Internship:
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Expiration date of CPR certification:
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Anticipated date of Graduation:
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List in order of preference the three places in which
you would like to do your internship. Include the name of
the director, the address and phone number.:
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List any certifications or experiences that will help
you in this internship:
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Provide a statement of any personal conditions or
situations that may affect your ability to complete the
requirements of the internship;
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