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Healthcare Provider Internship Application (Demo)

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You're viewing a demo of this application (controls have been disabled; changes cannot be saved). Visit each stage (1 through 7) to get an idea of the fields that are required.

To complete an actual application, you need to create an account (click the "Create new application" button below). If you already have an account, log in, then visit your profile.

Stage 1: Basic Information

Name

Last Name *

First Name *

Middle Name

Maiden Name

Birth

Gender: Male Female

Place of Birth *

Birth Date (mm-dd-yyyy) *

Contact

Email Address *

Mobile Phone

Home Phone

Work Phone

Address

Street/Box Number *

City *

State

Country *

Zip Code

Are you a U.S. citizen? Yes No

If no, what type of visa do you have? (please send supporting documentation)

None Tourist Permanent Religious

Social Security Number: Numbers only; no hyphens

Do you speak other languages, besides English?

Occupation

Occupation *

Marital Status

Children

List your children (Name, Date of Birth, Gender - 1 per line)

Are you responsible for child support? No Yes

If so, how much per month?

Emergency Contact

Person(s) to contact in case of emergency (Name, Address, Phone Number - 1 per line)

Arrival at Uchee Pines

When do you plan to arrive at Uchee Pines?

No Pets Policy

Do you understand that no pets are permitted at Uchee Pines Institute, and are you willing to comply with this?
No Yes

Handbook

The Master's Program Handbook (Updated 2020) is available for download.

I have read the Trainee Handbook, and agree to abide by the principles therein. Yes No

If no, please list any specific areas where you feel you cannot comply with institutional policy.

Finance

Do you understand there is a charge for tuition, room, and board? Yes No

How do you plan to finance the cost?

Visit Uchee Pines!

Contact

Uchee Pines Institute
30 Uchee Pines Road
Seale, Alabama 36875

Phone (U.S. only):
1-877-UCHEEPINES
(1-877-824-3374)

Phone (Worldwide):
1-334-855-4764

Quick Links

Motto

Uchee Pines is committed to assisting people through the use of simple, natural methods, using exercise, vegetarian nutrition, hydrotherapy, massage, the rational and judicious use of some herbs and supplements, and firm faith in the Divine Healer.

“Get wisdom... get understanding.” (Proverbs 4:7)