Internship Request Form

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INFORMATION ABOUT THE REQUESTOR

Name of Requestor

Date of Request

Email Address

Phone Number

Are you a Catholic Health Employee?

Yes

If so, which site?

INFORMATION ABOUT THE SCHOOL AND DEGREE

Name of School

Contact at School

Email Address

Phone Number

Intern Start Date

Intern End Date

Intern Site

Intern Area/Department (e.g. radiology, PT, finance, nursing)

Will you earn college/school credit for this internship?

Yes

Degree Program (s) to include in Affiliation Agreement

Additional Information

Use the space below to provide additional information about this request (for example, the name of an employee who referred you).

FOR OFFICE USE ONLY

Date to CHS Legal

Date to School

Request Type

New Agreement

Amendment

Addendum

Renewal

Tuition Discount

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Internship Request Form

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