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Internship Application

Personal Information

Full Name: *
Date Of Birth: *
Street Address: *
City: *
State: *
Zip Code: *
E-Mail: *
Home Phone: *
() -
Cell Phone:
() -
Grad Date: *
Now
Last 4 Digits of SSN: *

Employment Information

Are You 18 years of age or older? *
Have you previously been employed by or worked for any of the Lancaster General Health entities? *
If yes, when and where:
Have you ever plead guilty or "no contest" or been convicted of any crime (to include misdemeanor or felony offense)? *
If yes, explain. Conviction of or pleading guilty to or no contest to a crime will not necessarily disqualify and individual.

Education

College / Univeristy 1 * College / Univeristy 2 College / Univeristy 3
College or University: *
College or University:
College or University:
City: *
City:
City:
State: *
State:
State:
Major: *
Major:
Major:
GPA: *
GPA:
GPA:
Year of Study: *
Year of Study:
Year of Study:
Minor:
Minor:
Minor:
Degree Expected:*
Degree Expected:
Degree Expected:

Internship Information

Please review current internship positions listed on the website and list up to 3 departments/positions that interest you. You must list at least 1 department/position.
Department 1 *
Department 2
Department 3
Please answer the following questions:
1. Describe your interest in the department(s) listed above and how they relate to your field of study.*
2. Explain what you hope to gain from an internship at Lancaster General Health. *
3. How did you hear about Lancaster General Health's internship program? (Example: newspaper, website, advisor, etc) *
Availability Please note: Information entered here reflects the applicant's preferences only, and is intended to gather details about availability. Requirement regarding hours, shifts, and scheduling vary by department and position.
Do you have a minimum hour requirement? If so, please list
Desired Start Date: *
Now
Desired End Date:
Hours available to work per week (full time = 40 hours per week) *
I am available on the following days (check all that apply)*
               
Any Day
Monday  
Tuesday
Wednesday
Thursday  
Friday
Saturday  
Sunday
               
Please list any specific details about your availability and requirements below

Resume & References

Please submit your resume and cover letter as a required part of your application package. These documents must be typed or pasted in plain text (no tabs or special characters).
Resume:
Upload:

References Please list three professional or academic references. You may list former managers, supervisors and/or educational references such as professors or advisors. Friends and relatives should not be listed.
Reference 1 * Reference 2 * Reference 3 *
Name: *
Name: *
Name: *
Title: *
Title: *
Title: *
Address: *
Address: *
Address: *
Phone: *
() -
Phone: *
() -
Phone: *
() -
E-mail: *
E-mail: *
E-mail: *
Relation: *
Relation: *
Relation: *

Read the Following Carefully Before Signing

*My typed name below shall constitute an electronic signature and have the same force and effect as my written signature.

I hereby authorize Lancaster General Health and their representatives to consult with administrators/ supervisors and academic institutions with which I have been associated and with others who may have information bearing on my professional competence. I hereby release from any liability any and all individuals and organizations listed above who provide information to the Lancaster General Health and any member affiliate in good faith concerning my professional competence, educational credentials, ethics, character and other qualifications and I hereby consent to the release of such information. With the submission of this application I certify that all statements are true and correct to the best of my knowledge and belief. Any misrepresentation or omissions on this application may be sufficient cause for rejection of the application or dismissal from an internship. To commence an internship the following must be completed:
  1. TB Testing (completed by LG Health)
  2. Drug Screen (completed by LG Health)
  3. Criminal background check (completed by LG Health)
  4. Proof of Immunizations*
  5. Submission of Child Abuse Clearances*
*required for clinical internships only
Signature: *
Date: *
Now



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