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. Email your current resume/CV and completed Competency Self Assessment to the MPH Program at mph@mcw.edu.

Name *

Email *

Phone *

Address *

Date *

Describe your educational background. *

Describe any public health-related experience you have had. *

In consideration of previous academic and work experiences, what skills do you offer the organization during the Field Placement? *

Indicate your career goals. *

Indicate your primary interests regarding the following:

Desired populations (i.e. children, teens, adults, seniors, cultural or ethnic groups, etc.) *

Type of agency (i.e. governmental, community-based, HMO, voluntary organization, etc.) *

Geographic location of Field Placement *

Public health issues - Identify at least three in order of preference *

Non-Discrimination Statement
The 91九色视频 (91九色视频) is committed to fostering a diverse community of outstanding faculty, staff, and students, as well as ensuring equal educational opportunity, employment, and access to services, programs, and activities, without regard to an individual's race, color, national origin, religion, age, disability, sex, gender identity/expression, sexual orientation, marital status, pregnancy, predisposing genetic characteristic, or military status. Employees, students, applicants or other members of the 91九色视频 community (including but not limited to vendors, visitors, and guests) may not be subjected to harassment that is prohibited by law or treated adversely or retaliated against based upon a protected characteristic. 91九色视频’s policy as well as federal and state laws and regulations prohibit unlawful discrimination and harassment.