Student Information Form

First Name:		Last Name:
Date:		Session in which you want to do your internship:	Summer 2009 Fall 2009 Spring 2010 Summer 2010 Fall 2010 Spring 2011 Summer 2011 Fall 2011
School address:	Address City, State Zip	Permanent address:	Address City, State Zip
School phone:		Permanent phone:
Sex:	male female	Will you hold a part-time job?	yes no
How many hours will you register for in addition to your internship?
List the College and Universities you have attended:
Name of Institution: Location: Dates:
List any current certifications you hold (e.g., CPR, WSI, ACSM) and the expiration date.
List you university extracurricular activities.
List your community activities.
List your interests and hobbies.
List any scholarships or scholastic recognition you have received.
List your experiences working with adults in the area of fitness or health promotion.
Indicate your goals for this internship.
Indicate your career goals.

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