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    Field Placement Site Application
        * Required Field  
       
    Name of Organization:*
       
    Type of Organization:*
       
    Address:*
     
     
       
    Phone:*
       
    Fax:
       
    Email:*
       
    Agency Website:
       
    How many students can your organization accept at one time?
       
    May prospective interns contact you directly? Yes             No
       
    Preceptor Name:*
       
    Preceptor Title:*
       Preceptors must have substantial experience in public health or a related field.  Please email a copy of your resume/CV to the Program Coordinator at mph@mcw.edu
       
    Anticipated Start and End Dates
       
    Is your agency able to offer a stipend or other financial compensation for the student? Yes             No
       
    If yes, provide an estimate of monetary or other form of compensation.
       
    Please provide a brief description of the types of public health projects or activities in which you envision the student being involved.
     
    Please list minimum qualifications (experience, computer skills, languages spoken, etc.) you require of the student.
     
    If possible, please send any brochures or materials that would be useful in describing your organization to students and Faculty Advisors.
         MPH Program
         Institute for Health and Society
         Medical College of Wisconsin
         8701 Watertown Plank Road
         Milwaukee, WI 53226
         		 Phone:  414-955-4510
    Fax:  414-955-6529
    Email:  mph@mcw.edu