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2. Pitt County Health Department Student Placement Application
   Student must be at least 16 years of age.
4. First Name*
5. Last Name*
7. Local Mailing Address*
   Include House/ Apt #, Street, City, State and Zip Code
9. Permanent Mailing Address*
   Include House/Apt #, Street, City, State and Zip Code
11. Cell / Primary Phone Number*
    Include Area Code
12. Alternate Phone Number
    Include Area Code
14. Fax Number
    Include Area Code
15. Email Address*
17. Name of School Attending:*
19. School Mailing Address*
    Include Building Address, Street, City, State and Zip Code
21. List the semester and date you need to begin your placement *
22. List the number of hours you are required to complete*
23. List the deadline for hours completion*
25. List Your Major (College Students Only)*
    If you are not a college student, type "None" in box
28. Briefly describe your assigned project*
30. Are you a Federal Work Study Student?*
    -- Select One --Yes No

    Federal Work Study Students must submit verifying paperwork with this application.
32. List the name of one reference (teacher, principal, professor) who can describe your academia work ethic, performance and character*
33. List the phone number of this reference*
34. List the email address of this reference*
36. Requirement for All Students
    All students are required to attend the Pitt County Government Volunteer Orientation Training prior to beginning placement. The Pitt County Health Department Human Resource Officer will notify students of the date of this training. All students must sign a Confidentiality and Liability Release after attending this training and agree to abide by Pitt County Government and Pitt County Health Department policies. Interviews are also required before consideration of most placements. If the placement requires an interview, applicants will be contacted by the Pitt County Health Department to schedule an interview between the student and Employee Mentor. Applications for short term placement (up to 40 hours) must be submitted at least 4 weeks in advance of the requested start date. Applicants requesting placement exceeding 40 hours (but not semester long) must submit applications at least 8 weeks in advanced of the requested start date. Due to high demand and limited placement, applications for long term placement (Internships/Practicums) should be submitted as early as possible but no less than 12 weeks prior to the beginning of the semester in which the placement will begin. College students must submit a resume with this application. The resume must outline career goals, cumulative GPA, college course work, past volunteer work and other relevant activities. Federal Work Study Students must submit required, verifying paperwork with this application.
38. Application Submission
    Return this completed application to Jennifer.dickerson@pittcountync.gov or by U.S. Mail to Jennifer Dickerson, Pitt County Health Department, 201 Government Circle, Greenville, NC 27834. If there are available placement opportunities, selected applicants will be contacted for an interview. Pitt County Health Department, Pitt County Government does not discriminate on the basis of race, religion, sex, national origin or handicap basis. Applicants must bring a photo ID (Driver's License Preferred) to the scheduled screening interview. Applicants will be expected to sign a Legal Release of Liability upon placement and attend the New Volunteer / Student Orientation. Submission of this application serves as the applicant's verification that they are at least 16 years of age and serves as an agreement to keep all client information strictly confidential, to comply with all County policies and ensures that all information and responses on this application are true and accurate to the best of the applicant's ability. Minors will be required to obtain signed permission from their parent or legal guardian prior to beginning placement.
40. Parent or Legal Guardian's Name
    (Required for Minors Only)
41. Address of Parent or Legal Guardian
    (Required for Minors Only)
43. Phone Number of Parent or Legal Guardian
    (Required for Minors Only)
45. Resume
46. Federal Work Study Forms
47. Other Documents
49. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
51. Electronic Signature
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field