Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs... Hampton Creek/ Food Start-Up Spec
Trang 1Dietetic Internship Program Application Verify application requirements of each program to which you wish to apply
Not all programs use this form All information must be typed/printed
(Street) (Apt #)
Permanent Address
(Street) (Apt #)
Cell Phone Number (Phone number where you can be reached on
Appointment Day.)
E-mail address Social Security Number
Actual or Expected Date (Month/Year)
Baccalaureate Degree conferred DPD Course requirements completed.Actual or Expected Date (Month/Year)
Overall Undergraduate (See page 6.)
DPD (See page 6.)
Overall Graduate (If applicable)
Graduate Record Exam Results:
(If taken, include a copy with your application.)
· Not all programs require GRE scores
· Check each program’s admission requirements
· Leave blank if not applicable
Date Taken (Month/Year)
Verbal Score
Quantitative Score
Analytical Writing Score
Use the following steps with Word 2007, to unlock this document so it is editable, i.e you are able to modify box sizes, font etc
Trang 21. Open the file in Word
2. Click on Review tab (at top of page)
3. Click on Protect Document (usually at far right)
4. Click on Restrict Formatting and Editing
5. Click on Stop Protection
6. The form is now unlocked and editable Treat it as you would any table in a Word document
7. After making edits, click on “Yes, Start Enforcing Protection” When the dialog box appears, just click “ok” without entering anything into the password fields This allows you to once again jump between fields with the tab key and the drop down boxes, work as intended
Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs
Trang 38 Education: List all colleges or universities attended, with most recent listed first.
College/University College/Univeristy City and State of Start and End Dates (Month/Year) Degree
Recommendations: List the names of the 3 individuals who will complete your recommendation forms.
Coni Francis PhD, RD Nutrition and Dietetics Assistant Professor
Program
University of Northern CO Gunter 2280
Campus Box 93 Greeley, CO 80639
Email:
constance.francis@unc.edu Phone: 970-351-1489
Catherine Gerweck, DMD,
University of Northern CO Gunter 2280
Campus Box 93 Greeley, CO 80639
Email:
catherine.gerweck@unc.edu Phone: 970-351-2755
Caroline Love Vice President of Operations
Hampton Creek
371 10th Street San Francisco, CA 94103
Email: cvlove@gmail.com Phone: 844-423-6637
Honors and/or extracurricular activities after beginning college: List organizations, appointed or elected offices held, scholarships, honors, and certifications received Include dates for honors
Golden Key Honor Society 07/15
ServSafe Certification 07/15
Professional Organization Memberships: List professional organizations of which you are a member
Academy of Nutrition and Dietetics
Oregon Academy of Nutrition and Dietetics
Trang 4
Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs
Trang 5Work experiences in the past five (5) years: List all experiences, including volunteer, beginning with the most recent Indicate if the experience was paid, volunteer or part of a practicum/field experience associated with a college course Briefly describe key responsibilities When indicating the amount of hours, use hrs/wk for reoccurring work and volunteer experiences and total hours for limited time volunteer and practicum/field experiences (Note: if you have professional dietetics work experience from over five years ago, you may include it.) Use additional pages as needed
Name of Employer / Organization Position Title Start and End Dates
(Month/Year)
Hrs/Wk
or Total Hours Paid, Volunteer,or Practicum
1 Hampton Creek/ Food Start-Up Specialist Relationship 1/14-8/15 Hrs/Wk 20-40 Paid
Supervisor’s Name and Title: Melanie Myers/Corporate Partnerships Team
Email:
mmyers@hamptoncreek.com Phone: 832-457-6326 Key Responsibilities:
Sales and marketing
of food products
Traveled to trade
shows to promote
products
2 Good Samaritan Regional Medical
Center Volunteer Dietetics 8/13-1/14 2 Hrs/Wk Volunteer
Supervisor’s Name and Title: Sara Thomas MS, RD, LD/Nutrition Manager
Email: sathomas@samhealth.org Vol
Phone: 541-768-5422 Key Responsibilities:
Assisted with research,
appointment setting,
reviewing recipes,
and Oncology
Lending Library
3 Samaritan Pacific Communities
Hospital Practicum 8/13, 03/15 15 Hrs/Wk, 12Hrs/Wk Practicum
Supervisor’s Name and Title: Erin Dooher RDN, LD/Dietitian Email: edooher@samhealth.org Phone: 541-574-1815
Key Responsibilities:
Shadowed dietitian on
clinical rounds
Attended diabetes
education class,
observed nutrition
counseling sessions,
observed charting in
Epic, and reviewed
case files prior to
rounds
4 Corvallis Environmental Center Event Planner 4/13-5/13 37 Total Hours Volunteer
Supervisor’s Name and Title: Jena Botte/ECI Outreach Coordinator Email: corvallisenvironmentalcenter.org
Phone: 541-753-9211 Key Responsibilities:
Planned events, solicited
and collected
donations, made
event baskets, and
did research
5 Oregon State University/Cascadia
Market Service/Food Prep Customer 08/11-09/13 20 Hrs/Wk Paid
Supervisor’s Name and Title: Jim Hoffman/Manager Email: jim.hoffman@oregonstate.edu
Phone: 541-737-3696
Trang 6Key Responsibilities:
Prepped food, served
customers, cleaned,
opened and closed
market
6 Market of Choice Customer ServiceClerk 09/10-03/11 20 Hrs/Wk Paid
Supervisor’s Name and Title: Cody Whitlock/Assistant Manager
Email:
codyw@marketofchoice.com Phone: 541-758-8005 Key Responsibilities:
Put together food orders
for delivery, customer
service, cleaning, and
facing shelves
Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs
Trang 7Work experiences in the past five (5) years, continued
Place of Employment
and/or Practicum Position, Title Start and End Dates(Month/Year) or Total HoursHrs/Wk Paid, Volunteer,or Practicum
7 Benco Direct Client Care 03/10-09/10 Hrs/Wk 16-20 Paid
Supervisor’s Name and Title: Rachel Derry/Supervisor
Email: racheld@bencocorvallis.com
Phone: 541-231-4929 Key Responsibilities:
Assisted disabled clients
in their home with
activities of daily
living Cooked meals,
administered
medications, provided
transportation, and
charted log notes
8 Mutual of Enumclaw Insurance
Company Claims Adjuster II 04/08-08/09
40-45 Hrs/Wk Paid
Supervisor’s Name and Title: Jason Murdock/Liability Claims Examiner
Email:
JMurdock@mutualofenumclaw.com
Phone:360-825-2591 Key Responsibilities:
Interviewed clients,
managed injured
client case files,
investigated liability,
reviewed medical
records, explained
benefits, interpreted
policies, set up
appointments and
made referrals
9 Farmers Insurance Representative Special Claims 06/92-06/07 Hrs/Wk 40-45 Paid
Supervisor’s Name and Title: Kathy Meisner/Liability Supervisor
Email:
kathy.meisner@farmersinsurance.com
Phone: 970-225-9306 Key Responsibilities:
Interviewed clients,
managed injured
client case files,
investigated liability,
reviewed medical
records, explained
benefits, interpreted
policies, set up
appointments and
made referrals
Supervisor’s Name and Title: Email: Phone:
Key Responsibilities:
Supervisor’s Name and Title: Email: Phone:
Trang 8Key Responsibilities:
Supervisor’s Name and Title: Email: Phone:
Key Responsibilities:
Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs
Trang 9Didactic Program in Dietetic (DPD) Courses: Include all courses required to meet DPD requirements at your college
or university If a course has not been completed, indicated INC in the No of Credits column See instructions on page 6 Use additional pages as needed (If you have earned credits from multiple educational systems that use different credit units, e.g semesters and quarters, you must convert all credits to one type of unit.)
College or University Prefix & No.Course CourseTitle PracticumLab / Term &Year CreditsNo of EarnedGrade GradePoints
Earned
Oregon State University 351 BA Managing Organizations No 2013 Spring 2.67 B 8.01 Oregon State University 319 NUTR Promoting Food & Nutrition No 2011 Spring 2.0 A 8 Oregon State University BI 212 Principles of Biology Yes 2012 Winter 2.67 B+ 8.01
Oregon State University
Z 331 Anatomy/Physiology Human Yes, Z
341 2012 Fall
1.33 lab 2.0 class
C-B- 6 2.66 Oregon State University
Z 332 Anatomy/Physiology Human Yes, Z
342
Winter
2013
1.33 lab 2.0 class
B A-
3.99
8
Oregon State University Z 333 Anatomy/Physiology Human Yes, Z
343
Spring
2013
1.33 lab 2.0 class
B+
C+
3.99
4
Oregon State University 230 MB Intro to Microbiology Yes 2011 Spring 2.67 A 10.68 Oregon State University 121 CH General Chemistry No 2010 Fall 3.33 C 6.66 Oregon State University 122 CH General Chemistry Yes 2011 Winter 3.33 C 6.66 Oregon State University 123 CH General Chemistry Yes 2011 Spring 3.33 A- 13.32 Oregon State University 331 CH Organic Chemistry No 2011 Fall 2.67 C 5.34 Oregon State University 332 CH Organic Chemistry No 2012 Winter 2.67 B 8.01 Oregon State University 350 BB Elementary Bio-Chemistry No 2012 Spring 2.67 B- 8.01 University of Northern CO
210 FND Medical Terminology No 2014 Spring 2.0 A 8
Oregon State University 240 NUTR Human Nutrition
Yes, NUTR 241
Winter
2011
0.67 lab 2.0 class
A
A
2.68
8
Oregon State University 325 NUTR Nutrition Through LifeCycle No 2011 Fall 2.0 A 8
Oregon State University 235 NUTR Science of Foods No 2012 Fall
0.67 lab 3.33 class
A-A-
2.68 13.32
University of Northern CO
FND
320
Nutrition Applications in Food Service Yes 2015 Summer
1.0 lab 2.0 class
A
A
4 8 University of Northern CO
FND
370
Nutrition Education and Application Strategies No 2014 Fall 3.0 A 12 University of Northern CO
FND
410
Professional Development
Seminar No 2015 Fall INC
Trang 10University of Northern CO
FND
430
Nutrition Assessment and Intervention Yes 2014 Fall
1.0 lab 3.0 class
A
B
4
9
University of Northern CO
FND
431
Medical Nutrition Intervention Yes 2015 Spring
1.0 lab 2.0 class
A A
4 8 University of Northern CO
FND
451 Advanced Nutrition No 2015 Spring 3.0 A 12 University of Northern CO
FND
452 Community Nutrition No 2015 Summer 3.0 A 12 Oregon State University 311 NUTR Food Service Productionand Purchasing Yes 2013 Winter 2.67 A 10.68 Oregon State University 202 PSY General Psychology No 2010 Fall 2.0 A 8 University of Northern CO
291 SCI Scientific Writing No 2015 Summer 3.0 A- 12 Oregon State University 150 STAT Intro to Statistical Methods Yes 2013 Summer 2.67 B 8.01 University of Northern CO
FND
420
Maternal and Child Nutrition No 2015 Fall INC University of Northern CO
FND
455
Nutrition For Fitness and Athletic Performance No 2015 Fall INC
Totals Credits
78.21
Total Grade Points
265.71
I certify the information I have provided in this application is true and accurate and recognize any false or incorrect statements made herein will be grounds for my dismissal from the program I understand I must provide an original copy of a signed Verification Statement substantiating completion of academic requirements prior to start date of program
11/18/15 Nancy Elwell
Prepared by The American Dietetic Association and Dietetic Educators of Practitioners Practice Group for optional use by dietetics education programs
Trang 11Instructions for Completing Grade Point Averages
CALCULATING UNDERGRADUATE GPA: (If you have earned credits from multiple educational systems that use different credit units, e.g semesters and quarters, you must convert all credits to one type of unit.)
·Example 1 – Pat completed all courses required for an undergraduate degree in nutrition from one university
o Pat should use the calculated GPA on the institution’s transcripts
·Example 2 - Sarah earned an undergraduate degree in sociology with a minor in nutrition She attended two community colleges and
a state university to fulfill all degree requirements She took several general interest courses while attending these colleges, although the courses did not meet any specific degree requirements These courses are listed on her transcripts Sarah also took a ceramics class at a fourth community college during one summer It was the only course she took from this college and is not one of the three colleges she attended to meet her degree requirements Sarah will calculate the Undergraduate GPA using the transcripts from the three institutions she attended where she earned credits towards her undergraduate degree Because Sarah did not transfer her ceramics course grade to her degree granting institution, it will not be included in the Undergraduate GPA calculation General interest courses Sarah took from the three credit earning institutions will be included
College/University 1 College/University 2 College/University 3
aTo calculate Grade Points Earned, multiply the number of credits times the GPA
for each respective institution separately
bTo calculate the Undergraduate GPA; divide the Total Grade Points Earned by
the Total Credits In this example: 423.58 ÷ 128 = 3.31
Total Grade Points Earned = 423.58
Total Credits = 128 Undergraduate GPAb = 3.31
CALCULATING DPD GPA:
Each university has specific courses which meets Didactic Program in Dietetics (DPD) requirements The DPD Director at the
university where you earned or will earn the Verification Statement indicating you are eligible to apply to a dietetic internship will have a list of these courses The following scale should be used to calculate Grade Points Earned for your DPD GPA For repeated courses, list both grades earned but use only the higher grade to calculate the DPD GPA
Grade earned Grade Points Earned
for each credit
Sample completed form:
College or University Prefix & No.Course Course Title PracticumLab / Term & Year CreditsNo of EarnedGrade GradePoints
Earned
A&P 202 Physiology (includes lab)
(retook class)
*INC Incomplete - currently enrolled or to be completed
Totals Credits 17
Total Grade Points 51