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Nurse Anesthesia Internship Application

Please complete all fields. 

 Full Name:
 Street Address:
 Zip Code:
 Phone (primary):
Phone (second, optional):
Email Address:
Major course of study:
Year in educational program:
Your specific goals for participation in this internship (what do you hope to gain?)  
Particular interests (internet, audio-video production, education, development of teaching materials, statistics tracking/analysis, medical/nursing science, etc.)


 Internships include varying amounts of time spent in office activities and in observation in the clinical area. Indicate your preference for participation in the following activities: 

Administrative work (filing, sorting, typing, gathering statitstics, etc.)


Clinical observation


Computer/multimedia (web site, power point, video production)

Indicate the number of hours per week you would like to serve in the internship.

Indicate which days of the week you would like to serve in the internship.

What time of day are you available?
Indicate your desired start date.  Tuesday, June 01, 2010 Select a Date Delete the Date
Indicate your desired end date.  Friday, August 20, 2010 Select a Date Delete the Date

Quick Reference

Nurse Anesthesia Program

(T) 336-716-1411
(F) 336-716-1412


7:30 am - 4:00 pm
Mailing Address 
Wake Forest School of Medicine
Nurse Anesthesia Program
525 Vine Street, Suite 230
Winston Salem, NC 27101  
Ways to Give
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