Dietetic Externship/Independent Study Program Application
Students for externship or independent study at Children’s of Alabama will be selected by committee and will be notified
before the end of April. Applications may be submitted via email or surface mail. Letters of recommendation must be
received by the deadline. Application packets can be mailed to: Department of Clinical Nutrition, 1600 7 th Avenue South,
Birmingham, AL 35233 Attention: Sue Teske, MS, RD, CNSD
Please provide the following information (print or type) and return the completed application no later than April 1st.
 Letter of interest describing your background, goals and specific objectives, proposed work/training program, what
you hope to gain or learn from the experience, and your availability
 Resume
 University/college transcript (unofficial copy is acceptable)
 2 letters of reference (educational or business)
 Completed and signed application form
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Dietetic Externship Program Application 2011
Date
Name
(Last)
(First)
(Middle or Maiden)
Present Address
(Street)
(Apt #)
xxx-xxx-xxxx
(City)
(State)
(Zip Code)
(Phone)
Permanent Address
(If different)
(Street)
(City)
(Apt #)
(State)
(Zip Code)
(Phone)
xxx-xxx-xxxx
Cell Phone Number
(Daytime Phone Number where you can be reached)
E-mail address
Actual or Expected Date (Month/Year)
Baccalaureate Degree conferred.
Major
Does your school require a report or written evaluation from the preceptor at Children’s?
Yes
No
Number of hours required by your school for the externship/independent study experience:
Preferred independent study/externship dates:
1st choice:
from:
to:
(specify dates)
2nd choice:
from:
to:
3rd choice:
from:
to:
Please briefly explain (250 words or less) why you should be considered as a summer extern at Children’s.
Please check the patient care and related area(s) of your interest:










Allergy
Lactation Services
Gastroenterology
Lipid Disorders
Endocrinology
Solid Organ Transplantation
HIV
Developmental Disorders
Ketogenic Therapy/Seizures
Infant Formula Preparation
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









Burns
NICU & NICU Follow-up
Rehab Medicine
PICU
General Pediatrics – inpatient
General Pediatrics – outpatient
General Surgery
Psychiatry
Specialty Surgery Services
Patient Food Services









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Hematology/Oncology
Weight Management 
LESTER® Program (wt mgmt)
Nephrology
Dialysis
Bone Marrow Transplantation
Intestinal Rehab
General Pulmonary Medicine
Cystic Fibrosis
Clinical Nutrition Management
Dietetic Externship Program Application 2011
Education: List all colleges or universities attended, with most recent listed first.
Address
Start and End Dates
College/University
(City/State)
(Month/Year)
Degree
Recommendations: List the names of the 3 individuals who will complete your recommendation forms.
Name
Title
Address
E-mail and Phone
Email:
Phone:
Email:
Phone:
Email:
Phone:
Honors and/or extracurricular activities after beginning college: List organizations, appointed or elected offices held,
scholarships, honors, and certifications received. Include dates for honors.
Professional Organization Memberships: List professional organizations of which you are a member.
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Dietetic Externship Program Application 2011
Work experiences in the past five (5) years: List all experiences, including volunteer, beginning with the most recent.
Indicate if the experience was paid, volunteer or part of a practicum/field experience associated with a college course.
Briefly describe key responsibilities. When indicating the amount of hours, use hours/week for reoccurring work and
volunteer experiences and total hours for limited time volunteer and practicum/field experiences. (Note: if you have dietetics
work experience from over five years ago, you may include it.) Use additional pages as needed.
Name of Employer / Organization
Position Title
Start and End Dates
(Month/Year)
Hrs/Wk
or Total Hours
Paid, Volunteer,
or Practicum
1.
Email:
Phone:
Supervisor’s Name and Title:
Key Responsibilities:
2.
Email:
Phone:
Supervisor’s Name and Title:
Key Responsibilities:
3.
Email:
Phone:
Supervisor’s Name and Title:
Key Responsibilities:
4.
Email:
Phone:
Supervisor’s Name and Title:
Key Responsibilities:
5.
Email:
Phone:
Supervisor’s Name and Title:
Key Responsibilities:
I certify the information I have provided in this application is true, complete and accurate and recognize any false or incorrect statements made herein
will be grounds for my dismissal from the program. I understand that the information provided on this form may be verified by contacting the persons or
organizations named in this application. I understand I am responsible for having at least two letters of recommendation and a copy of my academic
transcript sent to the Department Director for Clinical Nutrition at Children’s of Alabama no later than March 31st.
Date
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Signature
Dietetic Externship Program Application 2011