Unpaid Student Placement Request Form (Public Health)

Complete this form to seek placement for academic credit in our Public Health department.

Once you submit this form, we will advertise your interest internally and contact you if an opportunity is available.

Request Form

* = Required

Contact Information

xxx-xxx-xxxx  Invalid phone number

* Email Invalid email address

Education (College/University)

Coordinator / Professor

Phone xxx-xxx-xxxx


Invalid email address


Use your best estimate if you are unsure about your start and end dates.

* Available to Work      
Which days are you available?


(Example: 30 days x 7 hours = 210 total)

Do you have a vehicle to travel throughout the Niagara area? *
  Vehicle information required

Areas of Interest

* Check two divisional areas that you are most interested in.

Check two areas

* Describe your interest in the areas you selected:

Additional Comments

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.

All submitted personal information is protected by the Privacy Act.

Page Feedback Did you find what you were looking for today?