Please complete all sections of the Intern Data Sheet.

Applicant Information:

Internship Requirement:

Please provide school name, anticipated start date, number of hours needed and the deadline for completion of internship hours.

Host Department Information:

Please provide the name of your host department and the name of the supervisor of your internship with WellSpan.

Emergency Contact:


I hereby certify that all statements and answers set forth on the Data Sheet are true and complete to the best of my knowledge. I understand that any statements and/or answers are found false or information has been omitted, may be cause for rejection or termination of my internship. I also understand that if I do not fulfill the necessary internship requirements that my internship start date may be delayed or terminated.