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KRDHD Academic Group Experience Request

We appreciate your interest in learning more about the serves and programs of the Kentucky River District Health Department. To help us understand the type of knowledge and experiences you are expecting we request a representative from your group to complete the following application. We will review your application and be in contact regarding availability and opportunities related to your request.

1) Name of Academic Group requesting visit: *

2) Approximate number of students and faculty in your group? *

3) Contact person for the group: *

4) Contact Email *

5) University/College *

6) College/Department *

7) During which semester would you like to visit? *Fall (Aug-Dec)Spring (Jan-May)Summer (May-July)

8) Length of requested visit? *1-2 hoursHalf a dayWhole day2-3 days4-5 days

9) Do you have a specific date(s) in mind? *

10) Area of Interest (check all that apply) *AdministrativeHarm Reduction/Substance Use DisorderHealth PromotionHANDSBreastfeeding ProgramEnvironmentalFamily PlanningOther - Write In (Required)

If Other, please write in:

11) What skills, knowledge or program competencies do you hope is gained by this experience with the KRDHD? *

12) What benefit would this experience offer to the KRDHD and/or our communities in our efforts to address the social determinants of health? *

13) Other information you would like us to consider in your request. *

ADDRESS:

441 Gorman Hollow Rd.
Hazard, KY 41701
 (606) 439-2361
 (606) 439-0870

MEET US HERE!

NOTICE OF PRIVACY PRACTICES

KRDHD does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity).

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