Internship Application

Personal Information:

* First Name

* Last Name

* Email

* Street Address 1

Street Address 2 (Optional)

* City

* State -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

* Zip Code (5 digits)

* Phone

* Date of Birth

University Information:

* College/University

* Degree anticipated:

* Dates of internship:

* Number of hours required:

Supervisory credential requirements:

* Number of face to face supervision hours required:

* University Placement Coordinator:

* Coordinator's telephone:

* License and/or degree requirements for Agency Supervisor:

Other Information:

Please indicate any prior experience in working with children, adolescents and families.

Please include a brief paragraph about your goals for your internship:

Please include a brief paragraph about your career goals:

* Attach Your Resume (PDF or MS Word):