Dietetic Internship Application

DIETETIC INTERNSHIP APPLICATION

Applicant Name:    Date of Birth:

Program Selection

Preferred Track: Clinical Community/Public Health Foodservice/Management

Education

Prerequisite Coursework and Certifications

Indicate completion of core prerequisite courses. Check boxes indicate course completed; provide term and institution when completed.

Human Nutrition    Term/Institution:

Biochemistry    Term/Institution:

Physiology or Anatomy & Physiology    Term/Institution:

Microbiology    Term/Institution:

Food Science or Food Service Systems    Term/Institution:

Current CPR/First Aid Certification    If yes, expiration date:

Professional Experience / Supervised Practice

References

Attachments and Required Documentation

Please indicate documents you will submit with this application:

Resume / Curriculum Vitae

Official transcripts (undergraduate and graduate)

Verification of DPD coursework or verification statement

Immunization and health records

Background check consent (signed form to follow)

Program Policies, Certifications and Authorizations

Certification: I certify under penalty of perjury that the information provided in this application and any supporting documents is true, complete and correct to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information is grounds for denial of admission or subsequent dismissal from the dietetic internship program.

Authorization to Verify: I authorize the program to verify transcripts, educational records, professional licenses and certifications, and to contact references listed on this application. I authorize all educational institutions, employers and references to release information to the dietetic internship selection committee for purposes of evaluation.

Background Check and Health Requirements: I understand that acceptance is contingent upon successful completion of required health screenings, immunizations, and criminal background checks. Failure to meet health or background clearance requirements may result in rescission of an offer of admission.

Academic and Professional Conduct: I acknowledge that participation in the dietetic internship requires adherence to professional standards, confidentiality of patient information and compliance with clinical site policies. I understand that unprofessional conduct may result in corrective action or dismissal.

Non-Discrimination: The program admits applicants without regard to race, color, religion, sex, national origin, age, disability, or any other status protected by applicable law. Reasonable accommodations for documented disabilities will be considered in accordance with institutional policy.

Acknowledgement

By signing below I acknowledge that I have read and understood the policies and requirements set forth in this application and that submission of this application does not guarantee placement. I understand that acceptance into the program is a separate process and that additional documentation may be required prior to matriculation.

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