Internship Intake Form

Personal Information

First Name *

Last Name *

Date of birth *

Phone Number *

Email Address *

Address

Street Address

City

State

Postal code

Emergency Contact

Name: *

Phone Number: *

Academic Information

School / University: *

Program / Major: *

Academic Advisor or Internship Coordinator:

Phone / Email:

Internship Required for Graduation *

Yes

Total Hours Needed:

Internship Start Date:

End Date:

Availability

Days Available (check all that apply): *

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Available Time *

Morning

Afternoon

Evening

Location or Program:

Internship Goals and Interests

What are your goals for this Volunteer? *

What Area in our organization interest you most ( Check All that Apply) *

Social Services/ Case Managment
Out Reach / Community engagement
Administration / Office Support
Marketing / Communications
Event Planning / Fundraising
Housing Support Services
Mental Health Services
Other
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Skills and Experience

Do you have Prior Volunteer Or Work Experience ? *

Yes

If Yes, Please Describe Briefly

Languages Spoken

Relevant Skills or Certifications (e.g., CPR, Microsoft Office, Counseling):

Background Information

Have you ever been Convicted of a felony or Misdemeanor? *

Yes

If yes, Please Explain below

Are you willing to submit to a background check if required? *

Yes

Reference

Please provide one academic or professional reference:

Name

Number

Signature and Acknowledgment

I certify that the information provided is true and complete to the best of my knowledge. I

understand that submission of this form does not guarantee internship placement and that all

placements depend on availability and organizational needs.

Signature *

Clear