Application for Student Internship/Shadow

Personal Information

Name *

First

Middle

Last

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Phone *

Email *

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Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (If Different)

Address Line 1

Address Line 2

City

State

Zip Code

Student Application

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Type of Student *

Department *

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Assignment Start Date *

Assignment End Date *

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Number of Hours Per Week *

What program are you studying? *

Why do you want to be a student at River’s Edge Hospital? *

EDUCATION

High School/G.E.D.

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High School City and State *

Graduated? *

College

Year Completed *

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College City and State

Start Date

Graduated?

Year Completed

End Date

Degree/Major

Graduate School

Grad

Graduate School City and State

Start Date

Graduated?

Year Completed

End Date

Degree/Major

AGREEMENT - Please Read Thoroughly *

I agree to the statement below.

I hereby authorize the investigation of my background including all the information contained in this application. I understand that misrepresentation or omission of information in connection with my application and/or interview will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered.

I understand that my student experience at River’s Edge Hospital is subject to satisfactory completion of a criminal background study.

I understand that if I am selected by River’s Edge Hospital, my student experience will be "at- will", which means that either I or River’s Edge Hospital may terminate the student relationship at any time and for any or no reason. Finally, I also understand that while River’s Edge Hospital supports current policies, it retains the right to change them at any time, with or without notice to me.

I have read and understand the statements in this paragraph. By agreeing, I am also verifying information on my resume.

Signature *