Student Observation Application

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* 1. Name

Last Name

First Name

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* 2. Organization Information

Name of Organization

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

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* 3. Phone and Email Address

Daytime Phone

Email Address

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* 4. How many students are you looking for an observation opportunity for?

1-5

6-10

10+

I am looking for an observation for myself.

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* 5. Program Information

What is your program?

What degree are you pursing?

What year are you in your program?

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* 6. What health topic(s) are of interest?

Mental health

Nutrition

Physical activity

Reproductive health

Substance abuse

Diabetes prevention

Matter of Balance (fall prevention)

Oncology

Other (please specify)

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* 7. Details

What days of the week are you available to observe?

Times needed?

Hours needed?

Do you have a specific number of hours you are required to complete? If so, how many?

How many different programs/classes do you hope to observe?

Are you interested in youth health education, adult health education, or both?

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* 8. Have your students, or you as a student, been background checked? If yes, when?

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* 9. What made you interested in the Hult Center for Healthy Living as an observation opportunity?

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* 10. Anything else we should know?

It is important to know that the Hult Center for Healthy Living's mission is to 'empower people to live healthier lives'. Prior to the start of the observation, all students are required to have the following:

*Student observation orientation
*Expectation document read, understood, and signed
*Proof of a fingerprint criminal background check