UNIVERSITY OF ALABAMA AT BIRMINGHAM
UNIVERSITY OF ALABAMA AT BIRMINGHAM
PEDIATRIC PULMONARY CENTER
APPLICATION FOR NUTRITION TRAINEESHIP
Demographic Information
Name______________________________________ Email Address__________________
Permanent Address__________________________________________________________
Present Address_____________________________________________________________
Telephone (home)_________________________ (cell)____________________________
II. Education
A. Undergraduate College or University_______________________________________
Degree_________________ Major________________________________________
Year_________ Grade Point Average____________
B. Dietetic Internship (or CPD)_______________________________________________
Year__________ CDR Registration Number________________________
C. Graduate College or University____________________________________________
Degree________________ Major_________________________________________
Year__________ Grade Point Average____________
D. Current Academic Program ______________________________________________
Degree________________ Major_________________________________________
Anticipated Date of Graduation_________________________
Grade Point Average_____________
III. Related work experience in nutrition or the health care field:
List chronologically, voluntary and paid work experience, beginning with the most recent position: (You may also attached your resume or CV)
DATE NAME/LOCATION OF AGENCY TITLE OF POSITION/RESPONSIBILITIES
IV. Experience as a member of an interdisciplinary team in the provision of health care:
V. Honors, Awards, Activities, Professional Organizations :( Local, State, and National)
VI. Applicant’s Goals and Objectives for the Traineeship:
A. Objectives:
B. Special Interests:
VII. Applicant’s Career Plans:
A. Upon Completion of Graduate Study/Traineeship:
B. Long Range Goals:
VIII. REFERENCES (List three)
Name Address Phone Number
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
* A letter of interest should accompany your application. Additional information and/or requirements may be requested by the PPC Faculty.
LIST CLINICAL/COMMUNITY EXPERIENCE IN WORKING WITH THE MATERNAL AND CHILD HEALTH POPULATION WHILE IN YOUR UNDERGRADUATE PROGRAM, GRADUATE PROGRAM OR DIETETIC INTERNSHIP/COORDINATED PROGRAM
Name of Agency Observation and/or Experience (describe briefly) Clock Hours
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