General Information

________________________________________________
Name

________________________________________________
Address

________________________________________________
(City)                            (State)                            (Zip Code)

Phone (Day) ______________     (Evening) _____________

 


Ohio Licensure/Certification (RNs and graduate PTs)

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(State)            (Type of Licensure/Certification)           (Number)

 


College/University Information

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College/University

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Supervising Faculty Member's Name

________________________________________________
Address

________________________________________________
(City)                           (State)                             (Zip Code)

____________________________
Phone

 

Degree being pursued

(circle one)

Assoc.       Bachelors         Masters               Doctoral

______________________________________________
Discipline

 

Internship Requirements

Length of Internship requested:

           ____ Quarter           ___Semester           ___ Short Term (length) ___

Total # of Weeks ________

Dates Requested___________ to _____________

Primary Desired Focus for Internship
(circle one)

Cardiac Rehabilitation       Fitness/Exercise Science

Physical Therapy

 

Attachments:

Enclose the following materials:

  • Current resume with three references listed
  • Two written letters of recommendation (one from a professor in your field of study)

  • Letter stating goals of your internship experience and degree

  • Copy of current American Heart Association or Red Cross Healthcare Provider Basic Life Support card

  • Copy of liability insurance certificate