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Courier Program Public Health Internship

First Name:*

Middle Name:

Last Name:*

Home Address:*

City:*

State:*

Zip:*

Email Address:*

Phone:*

Current Age:*

Are you of Hispanic/Latino ethnicity or descent?

Select one or more races with which you identify yourself:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Preferred Pronouns:

School Name:*

School Address:*

School City:*

School State:*

School Zip:*

Major:*

School years completed:*

Degree Status:*

How did you hear about the Courier Program Public Health Internship?*

Short Answer Questions

What do you hope to gain out of this experience?*

What is your personal definition of servant leadership? In what ways do you embody these qualities(please use specific examples):*

What motivates you to serve as a Courier? How does the Courier program and the mission of FNU relate to your personal or career goals?*

Describe an encounter you've had with people different from yourself and demonstrate how you successfully navigated the experience.*

Is there anything else you feel would be relevant?

License Details

Couriers are required to provide their own transportation, insurance, and have a valid drivers licence. Will you have or will you be able to provide your own transportation for the session?*

Do you have valid vehicle insurance? *

Do you have a valid Drivers Licence?*

Drivers Licence ID Number:

Expiration Date:

State of Issue:

The following files must be submitted prior to completing the form

Copy of Unofficial Transcript (Please title the file "last name_Transcript." Example: Smith_Transcript)*

Please list three references below. Please include their name, title, and email address. The Courier Program Coordinator will reach out to all references to complete the reference letter process

Reference #1:*

Reference #2:*

Reference #3:*