Degree Type(Required)

Name(Required)

First Middle Last

Hidden

Date

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone Number(Required)

Email(Required)

Educational Institution(Required)

Major/Discipline(Required)

Advisor(Required)

Anticipated Graduation Year(Required)

Program Year(Required)

Please enter a number from 2000 to 2100.

Advanced placement

Yes

How many weekly hours are required by your program?

How many total hours are required by your program?

What are your anticipated start and end dates?

Start Date

Approximate End Date

Please describe preferences and/or special needs for type of placement, including preferences regarding desired geographical location or hours.

Do you have access to a car? (Required)

Yes

Do you have a valid driver’s license?(Required)

Yes

Do you speak more than one language?(Required)

Yes

What language(s) do you speak?(Required)

Please identify barriers such as work schedules or transportation limitations, which you would like us to consider in determining your placement.

Do you have a criminal record?(Required)

Yes

We ask that you divulge information about your criminal record to insure an appropriate placement as most sites require a background/ criminal records check. Please provide documentation of all criminal history including arrests, felony convictions, and/ or pending court involvement.

Have you ever been identified by a state child welfare agency as a risk to a minor?(Required)

Yes

Please explain below

Have you ever been accused of violations of academic standards?(Required)

Yes

Please explain below

Have you previously completed an academic placement or internship?(Required)

Yes

Please provide details below

Name of Agency

Summary of duties

# hours completed

Are you eligible to work in the US? [F-1 or J -1 Visa — international students](Required)

Yes

APPLICANT’S STATEMENT

I understand that my placement with Child and Family Agency is contingent upon successful completion of reference and background checks, and a physical health screening.
I understand that I must divulge potential conflicts of interest that may occur because of my or my family’s relationships with staff or clients at Child and Family Agency.
I understand that I am volunteering my services and have no expectation of receiving compensation or any in-kind benefits for my service.
I attest that all the information provided is accurate and complete to the best of my knowledge.

Application for Internship

Application for Internship

APPLICANT’S STATEMENT