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

* First Name

* Last Name

* Address

* City

* Province or State

* Postal / Zip Code

* Country

* Phone xxx-xxx-xxxx Invalid phone number

* Email Invalid email address

Education (College/University)

* School Name

Specify school *

* Department

* Course Name

Course Code

Year of Study

Coordinator / Professor

* First Name

* Last Name

* Job Title

Phone xxx-xxx-xxxx

Ext.

* Email Invalid email address

Placement

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

* Start Date mm/dd/yyyy

* End Date mm/dd/yyyy

* Available to Work Monday Tuesday Wednesday
Thursday Friday
Which days are you available?

* What hours can you work during the day?
to

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

Do you have a vehicle to travel throughout the Niagara area? *
Yes No 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

Provide any additional comments / questions that you have

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.