ࡱ> KMJ bjbj>> <%pTpT,88888LLL8<LG"2 2 2 G!G!G!G!G!G!G$ILLREG82 2 2 2 2 EG884ZGF%F%F%2 ^88GF%2 GF%F%@7D0 jwB, GpG0GBL 8LX7D7DL8KD2 2 F%2 2 2 2 2 EGEG2#2 2 2 G2 2 2 2 L2 2 2 2 2 2 2 2 2  : INTERNSHIP APPLICATION AND ELIGIBILITY REVIEW FORM {PUBLIC HEALTH EDUCATION MINOR} DEPARTMENT OF HEALTH PROMOTION AND PHYSICAL EDUCATION NAME: KSU#: PHONE:______________________ STUDENT E-MAIL: __________________________ 1. CURRENT OVERALL (ADJUSTED) GRADE POINT AVERAGE: _______________ *Must be minimum of 2.5 CURRENT GRADE POINT AVERAGE IN HEALTH PROMOTION MINOR CORE (PHE 2400, PHE 3850, PHE 4500, PHE 4600) Public Health Education Core GPA: *C or Higher in the Core Required Has this student made below a letter grade of C in any Public Health Education course? Yes____ No____ If YES please specify courses and appropriate action: ___________________________ 2. By initialing in the space provided, the student understands that he/she must provide proof of current professional liability insurance and proof of current CPR certification prior to starting the internship. ____________________ 3. Credit hours for internship and semester completing internship: Credit Hours: ________________ and Semester Year By signing below, the student and academic advisor confirm that the information provided is correct. _________________________________ Students Signature PHE Minor Program Coordinators Signature Date: Date: THIS APPLICATION MUST BE SUBMITTED TO DR. JANE PETRILLO, PROGRAM COORDINATOR, BY THE FOLLOWING DATES: June 1 for internships which will be completed during the Fall Semester November 1 for internships which will be completed during the Spring Semester March 1 for internships which will be completed during the Summer Semester   PAGE  -PAGE 1- 2345RSʸvdTBdT3h4yh"lPCJOJQJaJ"h4yhW5CJOJQJ\aJh4yh"lP>*CJOJQJaJ"h4yh Y 5CJOJQJ\aJ"h4yh"lP5CJOJQJ\aJhEa5CJOJQJ\aJ"hEahEa5CJOJQJ\aJhe5CJOJQJ\aJ"hEah35CJOJQJ\aJ&h4yh35CJOJQJ\^JaJ h"lP5CJOJQJ\^JaJ h4y5CJOJQJ\^JaJ34T/ I J i j 0^`0`gdSZ P^`Pgde`$a$(  - / G H J h i ߿߿uiu]]i]Nh4yh CJOJQJaJh4yCJOJQJaJheCJOJQJaJh4yhgBCJOJQJaJh4yh Y CJOJQJaJh4yh"lPCJOJQJaJh4yh 5CJOJQJaJh4y5CJOJQJaJh4yhK5CJOJQJaJh4yhgB5CJOJQJaJh4yh Y 5CJOJQJaJh4yhSZ5CJOJQJaJ  8 O Y Z i j ! ʺ蝎ssg[Lh4yhCJOJQJaJh CJOJQJaJhEaCJOJQJaJh3CJOJQJaJh4yh"lPCJOJQJaJh4yh(CJOJQJaJheh Y >*CJOJQJaJhe>*CJOJQJaJh4yh"lP>*CJOJQJaJh4yhgBCJOJQJaJh4yh Y CJOJQJaJheCJOJQJaJh4yCJOJQJaJ! ) 6 I T W _ c p q    & ( : ; L U ӥĸ~r~bbSSFbhEa>*CJOJQJaJh4yhWCJOJQJaJh4yh"lP>*CJOJQJaJh#CJOJQJaJhCJOJQJaJhS?CJOJQJaJh4yh(CJOJQJaJ%h h B*CJOJQJaJphhEaCJOJQJaJh4yh"lPCJOJQJaJh#h"lPCJOJQJaJh#h(CJOJQJaJh#hS?CJOJQJaJ ) * f g 5 & F h$88*$^8gdwF# & F h$88*$^8gd} & F h$88*$^8# ^`gde^ 0^`0gd e m q t z 񙍁uiZH"h#h 5>*CJOJQJaJh#h"lPCJOJQJaJh#h35\aJh#h 5\aJh#hW5\aJh#h"lP5\aJh4yh5\aJh4yh"lP>*CJOJQJaJheCJOJQJaJh CJOJQJaJhCJOJQJaJhCiCJOJQJaJhEaCJOJQJaJh4yh"lPCJOJQJaJ &'45=?@rsάΊ|t|n|n|n|d^d^Zh3 h30J'jh30J'U hoCJjhoUhojhoCJUheh5CJOJQJaJ"h#h35>*CJOJQJaJh#h}5CJOJQJaJ"h#h 5>*CJOJQJaJ"h#h"lP5>*CJOJQJaJh#h"lPCJOJQJaJh#h"lP5CJOJQJaJ! & F h$88*$^8gdwF#"$a$ "$&`#$a$""&`#$dɹheh5CJOJQJaJhoh3OJQJh3he0J'OJQJmHnHujh30J'OJQJUh30J'OJQJ :....()()))()() 0 000&P8$BP/ =!"#$% ^+ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H U Normal1$OJQJ_HhmH sH tH P@P  Heading 1$*$@& H5CJOJQJ\@\  Heading 2$$ *$@&a$5CJOJQJ@  Heading 3W$ H$d %d &d 'd *$@&N O P Q 5CJOJQJ@  Heading 4]$$ H$d %d &d 'd *$@&N O P Q a$5CJ4OJQJR@R  Heading 5$$ H*$@&a$ 5OJQJV@V  Heading 6$$  *$@&a$5CJOJQJ|@|  Heading 7?$ ) e$p  Z6*$@&5CJOJQJL@L  Heading 8$ H*$@& 5OJQJX @X  Heading 9 $$ *$@&a$5CJOJQJ\DA`D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 8+@8  Endnote TextCJ>*`> Endnote ReferenceH*:@:  Footnote TextCJ@&`!@ Footnote ReferenceH*NN TOC 1) $ 0*$]^`0JJ TOC 2% $ 0*$]^`0JJ TOC 3% $ p0*$]^p`0JJ TOC 4% $ @ 0*$]^@ `0JJ TOC 5% $ 0*$]^`0BB TOC 6 $0*$^`0:: TOC 70*$^`0BB TOC 8 $0*$^`0BB TOC 9 $ 0*$^`0N N Index 1% $ `*$]^``N N Index 2% $ 0*$]^`0>.>  TOA Heading *$ $."@. 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