RehabWorks - Internship Application

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Internship Application

Attention: Due to heightened security and badging requirements at this government facility, it will not be possible to except Non-US citizens at this time. Please accept our apologies.

Personal Information

First Name:	Last Name:
US Citizen:
Date of Birth: / /	Place of Birth:

School Information

School Name:
Street Address:
City:	State:	Zip:
Year/Classification:

Address Information

Street Address:
City:	State:	Zip:
Phone:
Email:

Permanent Address Information

Street Address:
City:	State:	Zip:
Phone:

Advisor Information

Academic Advisor's Name:
Street Address:
City:	State:	Zip:
Phone:

What semester are you considering to intern at KSC?

Is your college program accredited by the NATA?

How many years have you been involved with your college's Athletic Training Program?

What athletic training settings have you participated in?
(Choose all that apply)

Clinic
Professional
Corporate
Industrial
University/College
High School
Camps
Intramural/Club Sports

Why do you want to become an Athletic Trainer and what is your favorite aspect of Athletic Training?

How did you hear about the RehabWorks Internship Program?

What are your best personal attributes?

Select your top three strengths in athletic training:

Injury Evaluations
Therapeutic Modalities
Rehabilitation Design
Anatomy
Understanding of Injuries
Fitness/Strength Training
Knowledge of Rehabilitation Exercises
Outreach (presentations, educational material design)
Leadership Skills
Emergency Care
Acute Injury Care
Chronic Injury Care
Post Surgical Rehabilitation
Administration Tasks (SOAP notes, progress notes, time management)

Select your top three weaknesses in athletic training:

Injury Evaluations
Therapeutic Modalities
Rehabilitation Design
Anatomy
Understanding of Injuries
Fitness/Strength Training
Knowledge of Rehabilitation Exercises
Outreach (presentations, educational material design)
Leadership Skills
Emergency Care
Acute Injury Care
Chronic Injury Care
Post Surgical Rehabilitation
Administration Tasks (SOAP notes, progress notes, time management)

At this time in your education, if you were to choose your final professional occupation what would it be:
ATC
PT
PTA
PA
OT
Orthopedic Surgeon
General Practitioner
Paramedic/EMT
Educator
Researcher/Ex Phys.
Other:

If you were to work as an ATC what employment setting would you desire:
High School
College
Industrial/Corporate
Clinical
Professional Sports
Arts/Dance
Hospital
Military
Other:

Answer the following questions on a scale of 1-5.
(1=poor, 2=below average, 3=average, 4=above average, 5=excellent)

How do you feel about your skills in evaluating? 1 2 3 4 5

How do you feel about your skills in modality usage? 1 2 3 4 5

How do you feel about your skills in rehabilitation program design? 1 2 3 4 5

How do you feel about your skills in health and wellness? 1 2 3 4 5

How do you feel about your skills in computer use? 1 2 3 4 5

What would you like to obtain most from this internship?

What are your future goals?

	+ Freedom of Information Act + NASA Privacy Statement, Disclaimer, and Accessibility Certification		Editor: Erik Nason NASA Official: David A. Tipton Last Updated: May 2, 2007