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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

Ext.

Invalid email address

Placement

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

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.


All submitted personal information is protected by the Privacy Act.

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