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    Field Placement Student Interest Form

    Completion of this form will allow the Program Coordinator to assist you in meeting your interests and needs for the Field Placement.  Please submit this form four months prior to beginning your Field Placement, and email the Program Coordinator at mph@mcw.edu your current resume/CV and completed Competency Self Assessment.
     

     
         * Required Field  
       
    Name*
       
    Email*
       
    Phone*
       
    Address*
     
     
       
    Date*
       
    1. Describe your educational background.*
       
    2. Describe any public health-related experience you have had.*
       
    3. In consideration of previous academic and work experiences, what skills do you offer the organization during the Field Placement?*
       
    4. Indicate your career goals.*
       

    5. Indicate your primary interests regarding the following:

    a. Desired populations (i.e. children, teens, adults, seniors, cultural or ethnic groups, etc.)*
       
    b. Type of agency (i.e. governmental, community-based, HMO, voluntary organization, etc.)*
       
    c. Geographic location of Field Placement*
       
    d. Public health issues - Identify at least three in order of preference*
       
    6. Indicate semester(s) in which you plan to participate in the Field Placement.*