Unpaid Student Placement Request Form (Public Health)

Contact Information

* First Name

* Last Name

* Address

* City

* Province or State Provinces... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon States... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

* Postal / Zip Code

* Country Select one... Canada United States

* Phone xxx-xxx-xxxx  Invalid phone number

* Email Invalid email address

Education (College/University)

* School Name Select School... Brock University Lakehead University McGill University McMaster University Mohawk College Niagara College Trillium College University of Waterloo York University Other...

Specify School

* Department

* Course Name

Course Code

Year of Study Select Year... First Second Third Fourth Master's level

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?
Start Time 8:30 a.m. 9 a.m. 9:30 a.m. 10 a.m.  to  End Time 3 p.m. 3:30 p.m. 4 p.m. 4:30 p.m.

* 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.

• Chronic Disease and Injury Prevention Details
• Dental Health Details
• Emergency Medical Services Details
• Environmental Health Details
• Epidemiology Details
• Home Visiting Program Details
• Infectious Diseases and Vaccinations Details
• Mental Health Details
• Pregnancy and Prenatal Details
• School Health Details
• Sexual Health Details

Check two areas

* Describe your interest in the areas you selected:

Additional Comments

Provide any additional comments / questions that you have

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.