Student Application

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Student Application

Please complete and submit application for the Patient Navigation Internship Program

First and Last Name *

Email Address *

Phone Number (xxx) xxx - xxxx *

Undergraduate School of Attendance *

Undergraduate Major *

Undergraduate GPA *

Undergraduate Graduation Year *

Are you pursing any pre-professional programs (i.e. Pre-med, pre-dental, pre-pharm, etc) ? If yes, please describe. *

I understand this is a voluntary UNPAID internship *

Yes

I understand this program requires a 1 year commitment *

Yes

Required

How do you plan to commute to HealthSource of Ohio clinical sites? *

Have you applied to the HSO Patient Navigation Internship in the past? If so, when? *

Please list which HSO clinical site you would be able to travel to for your weekly assignment. *

Batavia Family Practice

Georgetown Family Practice

Hillsboro Family Practice

Lebanon Family Practice

Loveland HSO Admin office

Mt Orab Family Practice

Mt Washington Family Practice

New Richmond Family Practice

Seaman Family Practice

Washington Court House Family Practice

Other:

How did you hear about the HSO Patient Navigation Internship Program? *

References Needed

One professional and one peer.

Professional Reference *

A professional reference is an individual who has worked with or overseen you in a professional setting (e.g. advisor, mentor, supervisor, professor, or employer that is not a family member or friend). Please include reference person's name, reference email/phone, and relationship with applicant.

Peer Reference *

A peer reference is an individual who has known you for over three months, and has worked with you in an academic, professional, or extracurricular setting (i.e. leader of student organization, group member, fellow athlete). Please include reference person's name, reference email/phone, and relationship with applicant.

Supplemental Materials

Please complete two essays described below, and upload your most recent resume or curriculum vitae.

Essay #1 *

Define community service. What does community service mean to you? Max 250 words.

Essay #2 *

Essay #2: How can you help HealthSource of Ohio's Patient Navigation Internship succeed? Max 250 words.

Email Updated Resume/CV to navigationprogram@hsohio.org

subject: [PNI Application Resume/CV 2019] - Your First and Last Name

Submit

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