Wellness - Internship Site Fact Sheet
This form is to be completed by the potential internship site and returned to the institute.

Items with an * indicate a required field.
Today's Date *    
Internship Site *
Internship Supervisor's Name *
Title *
Address *
City *
State *
Zip *
Country
Phone *
Fax
Email
 
Type of Work Environment and Facilities
Check all that apply  Corporate/Office
  Manufacturing
  Skilled Labor
  Military
  Government
  University
  Health Care/Hospital
  Community Services
  Senior Citizens Center
  Entertainment/Restaurant
  Recreation/Fitness Facility
  Faculty/Staff/Students
  Children
  Older Adults
  Service Workers
  White-Collar
  Blue-Collar
  Not-for-profit
  Unionized Work Force
  Human Resources
  Other
If you checked 'other' please describe the work environment and facility
 
Types of Wellness/Health Promotion Services and Programs
Check all that apply  Fitness Facility
  Weight Management
  Comp Time
  Flex Time
  Health Screenings
  Walking Program
  Newsletter
  Tuition Reimbursement
  Child Day Care
  Self-Care Education
  Ergonomics
  Health & Safety
  Recycling
  Financial Planning
  Retirement Planning
  Stress Management
  EAP
  Aerobics
  Other
If you checked 'other' please describe the additional Wellness/Health Promotion Services and Programs
 
Compensation
Check all that apply  Meals
  Housing
  No Compensation
  Stipend
  Other
If you checked 'stipend' please include the amount and whether it is per hour or per week etc.
If you checked 'other' please describe the alternative form of compensation
 
Intern Certification Requirements
Check all that apply  CPR
  First Aid
  Proof of Liability Insurance
  Other
If you checked 'other' please describe additional Intern Certification Requirements
 
Application Requirements
Check all that apply  Letter of Application
  Resume
  Transcripts
  References
  Other
If you checked 'references' pleast list the number required
If you checked 'other' please describe additional application requirements
 
Additional Comments
Please feel free to include additional information that would provide a clearer overview of the organization and its wellness/health promotion services, programs, and activities.

Any program and promotional materials can be mailed or faxed to:

Dr. Jane Ellery
Associate Director
Program Director of Wellness Management
Fisher Institute for Wellness and Gerontology
Ball State University
2000 W. University Avenue
Muncie, IN 47306
(765) 285-8259 (Main Office)
(888) WELLBSU (Toll-free)
(765) 285-8237 (Fax)
 
Thank you once again for you interest in participating with the Fisher Institute for Wellness and Gerontology as an Internship Site for our Wellness Management student(s). We look forward to a mutually beneficial relationship!