STUDENT  DATA  INFORMATION   SHEET

Name:                                  _____________________

Phone:                                  _____________________          

Current Address:              _____________________

                                                _____________________

Permanent Address:        _____________________

                                                _____________________

E-mail:                                   _____________________

Semester of current internship (circle)          

Fall   __ (yr)               Spring __ (yr)           Summer __ (yr)

Internship Site

            Agency:         _____________________           Dept.: ______________

            Address:        _____________________

                                    _____________________

            Supervisor:   _____________________           Title: ________________

            Supervisor’s

            Phone:           _____________________

            Your phone:  ____________________

How many credits of internship are being taken?         ____

Total hours per week at internship:                                  ____

List career ambition here:

ATTACH A COPY OF YOUR APAS TO THIS FORM. 

Turn this form in PRIOR to beginning your internship.

Return this form to:             

Dr. Ladona Tornabene

Associate Professor, Health Education        

University of Minnesota Duluth          

1216 Ordean Ct., 110 SpHC, Duluth, MN 55812

Phone:            218.726.7522

                        Fax:                 218.726.6243