Internship/Student Rotation Application Form

Thank you for your interest in an internship or clinical rotation position with the Florida Department of Health in Orange County.

For Nursing Rotations: include the behavioral objectives for your rotation. You can also email them to Jennifer.mills@flhealth.gov.

Interns and students must complete all sections of this application.

Once you complete the form, click the submit button at the bottom.

Section 1a: Personal Information

First name:

Last name:

Middle name:

Application Type:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

Age range:

Section 1b: Emergency Contact Information

Please provide a name, phone number and relationship of an emergency contact for you.

First name:

Last name:

Contact's phone:

Relationship:

Section 2: College/Education Information

Please complete this section if you are applying for an internship or rotation with the Florida Department of Health in Orange County. Include the contact information for your school's Intern Coordinator.

Education:

Major degree:

School/College:

Internship Coordinator Name:

Internship Coordinator Phone:

Internship Coordinator Email:

I would like to serve up to:

hours:

Section 3: Areas of Interest

Please choose your top 3 choices of areas you wish to intern. Applicants will be assigned
depending on availability of space in each area.

* Assignment Preference:

1st choice:

2nd choice:

3rd choice:

Section 4: Availability

Specify the days and time frames you are available to intern.

Section 5: Background Information

If you have ever been convicted of or plead nolo contendere to a driving or criminal offense please explain (including types of offenses and dates):

Agreement to Screen and Affirmation of Information

It shall be a misdemeanor of the first degree to fail to disclose, by false statement,

misrepresentation, impersonations or other fraudulent means, any material fact used in making

a determination as to a person's qualifications to work as a volunteer.

I understand that, to protect persons served by the department, a routine check through law

enforcement, license bureaus, agency files, and references may be made. I understand that a

criminal offense will not automatically exclude me from all volunteer positions; however, certain

convictions will exclude me from volunteering in some positions. I understand that if I answered

no to the criminal offense question on the front of this application and a record should be

obtained, it will prevent me from volunteering for the department regardless of the offense. I

understand upon submission of this application it becomes public record.

I understand and agree that all information as it relates to persons served by the department is

to be held confidential in compliance with Florida Statutes. All information that should come to

my attention and knowledge as privileged and confidential will not be disclosed to anyone other

than authorized personnel and that I shall conduct myself in accordance with the departmental

security policies. I understand that failure to comply may result in criminal prosecution.

I affirm that all information on this application is true and correct.

I Agree