Student Request Form

Please refer to the application period in your desired program before submitting this request. Contact Us: For additional questions, please e-mail the Education Coordinator at kira.king@jocogov.org or call (913) 477-8337.

Contact Information

Full Name *

Phone *

School E-mail Address *

Course # and Title *

School *

Instructor Name *

Program Preference

1. Child Care Licensing
2. Environmental Health
3. Strategic Planning, Population Health Epidemiology (master’s only)
4. Strategic Planning, Workforce Development
5. Health Clinic
6. Health Clinic, Social Work
7. Health Services, Epidemiology/Disease Investigation
8. Community Health, General
9. Community Health, Outreach Nurse Program
10. Community Health, Social Work
11. Community Health, Dietetics (WIC)

Selected Programs *

Select the programs for which you are requesting interviews: select 1st, 2nd, and 3rd choices.

Internship Requirements (availability)

Total # hours *

# hours per week *

Semester of Internship *

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