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REV 04/08/2016
Palomar Health ● Pathmaker Internship Internship Application
DIRECTIONS: Step 1: Save this blank application to your computer. Please do not complete it straight from your browser.Step 2: Fill out the application electronically. Step 3: Save your completed application and email your final application to [email protected]. Please make the subject of your email “Last Name, First Name—Application”, so that we can easily identify you.
Last Name First Name
MI Application Status Are you 16 or over?
Yes No -SELECT YOUR STATUS
Local Address City, State Zip Code Additional Languages Spoken Fluently:
Spanish
Other
Permanent Address
City, State
Zip Code
Home Phone (xxx)xxx-xxxx Mobile Phone (xxx)xxx-xxxx Email Address
High School Attending
Are you currently enrolled in a Healthcare Academy/Pathway?
Yes No Health Fundamentals/Science Teacher:
CUM GPA Grade Career Goal Other Specify
-GRADE- -SELECT YOUR CAREER-
Current Employer (If applicable) How did you hear about the Pathmaker Internship?
-SELECT- Name of Person or Organization:
PROFESSIONAL/ACADEMIC REFERENCES List two Professional or Academic references (supervisor/instructor) who could speak to your performance.
Please keep in mind that your references will be required to fill out a brief survey on your behalf. We will email the survey link
directly to your reference according to the timeline provided on our website. Your application will not be reviewed if your references do not complete the survey, so please plan accordingly.
Reference #1 Name Reference #1 Relationship Reference #1 Email Address
Reference #2 Name Reference #2 Relationship Reference #2 Email Address
CONTACT INFORMATION
2016 C
CONTACT INFORMATION
REV 01/13/2016
Palomar Health ● Pathmaker Internship Internship Application
2016 C
All applicants will be responsible for completing the Essay and Short Answer Prompts. Additional prompts must be completed by Re-Applicants or Former Interns. Prompts must be answered in well-formulated paragraphs. Essay Prompt: Why would you like to be a Pathmaker Intern? What are three goals you hope to accomplish
within our program and why? How do you plan to achieve these goals? (2500 character max, including spaces.)
REV 01/13/2016
Palomar Health ● Pathmaker Internship Internship Application
2016 C
Short Answer Prompt: As a Pathmaker Intern, how will you uphold Palomar Health’s mission and vision? (1250 character max, including spaces.)
Re-Applicant/Former Interns:
Re-Applicant Prompt: How have you better prepared yourself since your previous application to the Pathmaker Internship? (1250 character max, with spaces.) Former Intern Prompt: What were the reasons you exited the internship? Why do you want to return? What will be different? (1250 character max, including spaces.)
REV 04/08/2016
Palomar Health ● Pathmaker Internship Internship Application
2016 C APPLICANT AFFIRMATION
Please read and initial each of the following:
_______ 1. I affirm that everything submitted in my Pathmaker Internship application is complete and true to the best of my knowledge, and that if any items are found to be falsified, I will no longer be considered for candidacy.
_______ 2. I affirm that I will not share, distribute or post electronically, any of the questions presented during my
interview and that if I am found to have distributed anything related to the interview questions, I will no longer be considered for the Pathmaker Internship
_______ 3. I affirm that I reviewed and understand the dates and clearance items listed in the Program Requirements
Packet for On-Boarding and Orientation and I understand that I may be quizzed on this information at my interview.
_______ 4. I affirm that to the best of my knowledge, I will be present and able to attend at least one shift per week
through the entire span of my first official rotation as an intern (September 1, 2016– November 30, 2016) and understand that I will not be eligible for any leave from the internship of more than 14 days until I have successfully completed this first rotation.
MEDIA CONSENT
I, ______________________________________________________ (print name), hereby grant permission to Palomar Health, to take and use: photographs, videos, audio, and/or digital images of me for use in news releases and/or educational materials including, but not limited to: dissemination to healthcare professionals and/or members of the public for treatment, research, medical, scientific, and teaching in the form of printed or electronic publications, websites, or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s). I will be informed of any material released outside of the Pathmaker Internship. I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of the Pathmaker Internship.
I authorize such use subject to the following restrictions/limitations (if any): __________________________________________________________________________________________________________________________________________________________________________________________________________________
CONFIRMATION OF APPLICATION
By signing below, I certify that all items above are accurate to the best of my knowledge. I understand, and agree to the expectations listed in the affirmation and media consent by applying to the Pathmaker Internship. As a parent/guardian, by signing below, I confirm I also agree to what has been stated and affirmed in this application.
I understand and agree that in the performance of my duties as an intern at Palomar Health I will abide by all policies and procedures, including attendance guidelines and information privacy. I understand that failure to comply with these requirements may result in my dismissal as an intern.
APPLICANT SIGNATURE DATE
PARENT/GUARDIAN SIGNATURE (if under 18)
DATE
My typed name above will have the same effect as my written signature.
My typed name above will have the same effect as my written signature.
