Contact Information

Name

Telephone

Email

Education (College/University)

School Name

Major / Faculty

Course

Year of Study Select Year... First Second Third Fourth

Coordinator / Professor

Name

Telephone   Extension

Email

Placement

Start Date

End Date

Which days are you available to work?
Monday   Tuesday   Wednesday   Thursday   Friday

What Hours can you work during the day?
Start Time 8:30 a.m. 9 a.m. 9:30 a.m. 10 a.m.  to  End Time 3 p.m. 3:30 p.m. 4 p.m. 4:30 p.m.

In total, how many hours will your placement be?
  (Example: 30 days x 7 hours = 210 total)

Do you have transporation to travel throughout the Niagara Region? Yes No

Check Three Program Areas that you are Interested In     

Active Living
Dental
Early Detection of Cancer
Environmental Health
Epidemiology
Healthy Babies/Healthy Children
Healthy Eating
Immunizations
Infant and Child Development
Infection Prevention and Control
Injury Prevention
Mental Health
Reproductive Health
School Health (Elementary School)
School Health (Secondary School)
Sexual Health
Substance Misuse Prevention
Sun Safety
Tobacco Free Living

Additional Comments

Any additional comments/questions that you have

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