Internship Application
Internship Application Request Form

Full Name:


Program:


Are you currently in a program?
 Yes      No

If yes, what degree are you seeking?


If yes, what school are you attending?


If no, what degree are you planning on seeking?


If no, what school are you planning on attending?




Category:
  PT
  ATC
  OT
  RN


Type of internship:


Date Requested:


Preferred Location:
  AI Main Campus
  AI Satellite Rehab Clinics

Phone Number:


Email Address:


Reference:


How did you hear about us: