Nutrition & Dietetics: Online Internship Form

Supervised Practice Facility Information

Distance Dietetic Internship

Note: All fields are required.

Student Name:
Type of Affiliation (please check):
Foodservice	Nutrition Therapy	Community
Business/Entrepreneur	Other

Name of Facility:
Address:
Facility accredited/licensed by:
Used as a practice site for the following courses/rotations:

Maximum number of students from this program in this facility at one time:
Length of time students from this program assigned to this facility:
Maximum number of dietetics students from this and other programs in this facility at one time:

Number of Dietitians:	Total		RD		Advanced Degree
number of dietetic technicians:	total		DTR

Brief description of facility/agency/institution (mission, population served):

Brief description of department, including services performed, number of employees, and number of individuals served:

Brief summary of experiences provided for students:

Nutrition & Dietetics Dept. | O'Neill Center for Healthy Families, Room 221 | (570) 348-6277 | nutrition@marywood.edu