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

Verify your Submission

Verify your submission by typing the 6-digits you see in the box:

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