Student Internship Application

This information will be kept confidential and used only in conjunction with this program.

First Name*

Middle Initial*

Last Name*

Pronouns (optional)

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If you selected "other" and would like to disclose, please type pronouns below.

Address*

Email Address*

Phone Number*

School*

In order to request an internship, your school must be affiliated with Mount Nittany Health. If your school does not have an affiliation agreement, a representative of your school will need to contact the Education Department at education@mountnittany.org or 814.231.7174.

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Degree/ Certification Program*

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Major*

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If other:

In order to apply, you must be enrolled in an academic course that requires an internship to fulfill credit. If you are not enrolled in a course but would like to gain healthcare experience, please visit www.mountnittany.org/volunteer.

Required for Course Credit?

Advisor/ Instructor Name*

Advisor/Instructor Phone Number*

Advisor/ Instructor Email Address*

Semester*

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Requested Start Date*

Requested End Date*

Graduation Date*

Number of Hours per Week*

Available Days of Week

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Available Shift(s)*

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Available Shift Length

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Total Internship Hours*

Please indicate your primary and secondary department preferences below. If your preferred department does not appear in the dropdown menu, this indicates that the department is at capacity. Please select from remaining departments.

Primary Department Preference*

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Secondary Department Preference*

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Will you be performing any direct patient care during your internship?*

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Describe your expectations and personal goals for this experience.*

How do these goals contribute to Mount Nittany's mission and vision?*

Assigned Preceptor Name

If a current staff member already agreed to be your preceptor please list their name below.

I am a current Mount Nittany Employee or Volunteer

Attach Current Resume and Transcript*

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