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Student Internship Application
Last Name
First Name
Telephone
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Date of Birth
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Academy (If none type N/A)
Current Grade Level
Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian Email
Emergency Contact Name
Emergency Contact Phone
List any medical instructions(allergies, etc)
Physician/ Clinic
Physician/ Clinic Phone
Why do you want an internship? Specify areas of interests and skills. (1-2 paragraphs)
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