Skip to Main Content
Government
Doing Business
Services
How Do I...
Home
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Alcohol & Tobacco Compliance Training
Attorney's Office
Child Care Licensing
Child Foster Care Licensing
Community Corrections
Community Services
County
Minnesota Workforce Center
Public Health and Environment - Students
Public Health and Environment - Training
Public Works - Transportation - Comments
Sheriff's Office
Washington County Libraries
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Sign in to Save Progress
Request for Internship/Clinical Placement
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Student Information
This section is complete
This section is incomplete
2.
School Information
This section is complete
This section is incomplete
3.
Internship/Clinic Information
This section is complete
This section is incomplete
Student Information
First Name
Last Name
Telephone
Email
Address 1
Address 2
City
State
Zip
Are you a resident of Washington County?
-- Select One --
Yes
No
Continue
School Information
School Name
School Contact Name
School Contact Telephone
School Contact Email
Program of Study
Community Health
Nursing
WIC-Nutrition
Other
Degree
Graduate
Undergraduate
RN to BSN
Other
Other Description
Instructor Name
Instructor Telephone
Instructor Email
Address1
Address2
City
State
Zip
Continue
|
Go Back
Internship/Clinic Information
Required Number of Hours
Start Date
Start Date
End Date
End Date
Is there a project requirement? If so, please describe
Additional Comments
Also email a copy of the curriculum, student evaluation form/criteria and resume to PHE@co.washington.mn.us
Leave This Blank:
Submit
Submit and Print
|
Go Back
* indicates a required field
County Board
Community Services
Employee Portal
Environmental Center
Library
Parks and Open Space
Property and Taxation
Public Safety
Public Works
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow
