* 1. Name

* 2. Address

* 3. Cell Phone and Email Address

* 4. Best Time to Reach You

* 5. Educational Background--Highest Level of Completion

* 6. What school do you attend?

* 7. How did you learn about the Hult Center for Healthy Living?

* 8. What made you interested in wanting to intern at the Hult Center for Healthy Living? 

* 9. Please indicate how many hours you are needed to intern for.

* 10. Are there certain days/times that you prefer?

* 12. Have you ever been convicted of a felony? If yes, please specify. 

* 13. Is this an official internship through your school where you will receive credits? Is this an unofficial internship for experience only?

* 14. Describe any experience, skills, or talents you have that you feel would be beneficial to you as an intern at the Hult Center. Include any former volunteering and work experiences within the last six years.

It is important to know that the Hult Center for Healthy Living is a nicotine-free work environment and all interns must be nicotine free. All internships through the Hult Center are unpaid. Additionally, prior to the start of the internship, all interns are required to have the following:

*Updated proof of immunizations, including a flu vaccine (seasonal) and a TB Screen Test.
*Proof of an 11 -panel drug test, with acceptable results
*Proof of a fingerprint criminal background check
Cost of the above requirements is the responsibility of the intern.

* 15. By signing my name below, I understand that any false or misleading information furnished by my in this application form, or in connection with my application, may result in my dismissal.