Application for student internships, field experience and clinical placements

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Application for student internships, field experience and clinical placements

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Student information

Name

Date of application

Primary phone number

Secondary phone number

Email address

Street address

City

State

ZIP

Are you are resident of Bloomington, Edina or Richfield?

yes

no

Tennessen Notice
Please take notice that any data received by the City as the result of submitting this Web form will be classified as government data pursuant to the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Under the Data Practices Act, some or all of this data is classified as public data, including your name, address, email address, phone number, and other personal information provided by you. Public data is available to anyone requesting it and consists of all data furnished via this Web form. Please be advised that the correspondence will be added to the public record. The purpose and intended use of the information collected through this Web form is to assist the City in obtaining public input, recording RSVPs for an event and/or processing questions and concerns submitted via the form. You have the right to refuse to submit this form. If you choose not to submit this form, you will need to contact the City by another means if you wish to provide the information which this form collects.

The City of Bloomington does not discriminate against or deny the benefits of its services, programs, or activities to a qualified person because of a disability. To make a request for a reasonable accommodation, ask for more information, or to file a complaint, contact the Community Outreach and Engagement Division, City of Bloomington, 1800 West Old Shakopee Road, Bloomington, MN 55431- 3027; 952-563-8733, MN Relay 711.