Placement Request Form

Organization Name*
Department Name
Supervisor Name*
Prefix First Last
Title
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor Email*
Website
Phone
Our facility will participate in the Boston University Human Physiology Internship education experience in Academic Year 2024-2025.*
If YES, please complete the information on the next page.
Summer 2025 Number of students you can accommodate*
Summer Semester 2025 Application Deadline
Fall 2025- Number of students you can accommodate*
Fall Semester 2025 Application Deadline
Spring 2025 - Number of students you can accommodate*
Spring Semester 2025 Application Deadline
MM slash DD slash YYYY
Are any of these spots reserved specifically for BU Human Physiology students?
Brief Description of the Internship:*
Please describe the role, major tasks and responsibilities for the student.