Alliance student intern application Demographic information Question Title * 1. Please enter the following contact information: Name: School: Program: Anticipated degree: Email Address: Phone Number: Question Title * 2. What is your current address? Street City State Zipcode Question Title * 3. What is your permanent address, if different from your current address (e.g., parent's address)? Street City State Zipcode Question Title * 4. Start date: Question Title * 5. End date: Question Title * 6. Number of hours per week: Question Title * 7. Do you have a valid driver's license? (this is not necessarily required to complete an internship with Children's Health Alliance of Wisconsin)? Yes No Question Title * 8. Please enter your advisor information: Advisor name: * Advisor address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Advisor email address: * Advisor phone number: * Next