KINE 468 - Application to become an approved internship site

Thank you for your interest in becoming an approved internship site for the Kinesiology Department at SVSU.

*1.Do you currently have a SVSU student who is applying for an internship at your site?(Required.)

Yes. Please List student's name:

2.If you answered YES above, is the student currently employed by the site?

Yes

*3.What is the exact name of your site, as you would like it to appear on the Affiliation Agreement/Contract?(Required.)

*4.Please fill in your contact information below(Required.)

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

*5.Will you be serving as the preceptor for the student(s) at the site?(Required.)

Yes

6.If you answered YES to questions 5, please upload a copy of your current CV or resume to allow verification of exercise science related background/credentials

No file chosen

*7.Please check the types of internships below which would be offered at your site(Required.)

Corporate Wellness

Health & Wellness

Personal Training

Strength & Conditioning

Coaching

Physical Therapy

Occupational Therapy

Cardiac Rehab

Chiropractic

Orthotics/Prosthetics

Nutrition

Oncology Clinical Exercise

Physician Assistant

Pediatrics

Research

Other (please specify)

*8.Please fill in the information below for the person responsible for reviewing and signing the Affiliation Agreement/Contract(Required.)

First Name

Last Name & Credentials

Email address

Phone number

Thank you for completing the application to become an approved SVSU KINE internship site. You will be contacted by the internship coordinator if further information is needed prior to approval. Once approved, the internship coordinator will send the affiliation agreement for review and signature by the site.

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