Internship Application Name* First Last Phone*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleOtherHave a Fingerprint Clearance Card?*YesNoFingerprint Clearance Care Number*How did you hear about our internship program?*Why do you want to intern at S.E.E.K. Arizona?*What areas are you interested in? (Check all that apply)* Behavior Analysis Counseling Occupational Therapy Speech Therapy Infant and Early Childhood Developmental Preschool Direct Care Respite Support (HR,Finance, Compliance) Internship InformationName of School*Program/Major*Internship Start Date* Date Format: MM slash DD slash YYYY Internship End Date* Date Format: MM slash DD slash YYYY # of hours required*What is your availability during the internship days?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday What is your availability during the internship evenings?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Volunteer and Employment Information (1)Organization*Job Title*Contact Person*Phone*Describe work or volunteer service*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed/Volunteered from* Date Format: MM slash DD slash YYYY Employed/Volunteered to* Date Format: MM slash DD slash YYYY Reason for Leaving*Volunteer and Employment Information (2)Organization*Job Title*Contact Person*Phone*Describe work or volunteer service*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed/Volunteered from* Date Format: MM slash DD slash YYYY Employed/Volunteered to* Date Format: MM slash DD slash YYYY Reason for Leaving*Education (List current or most recent first)School*Program/Major/Degree*Attended from* Date Format: MM slash DD slash YYYY Attended to* Date Format: MM slash DD slash YYYY Graduation Date* Date Format: MM slash DD slash YYYY School*Type of degree or diploma*Attended from* Date Format: MM slash DD slash YYYY Attended to* Date Format: MM slash DD slash YYYY Graduation Date* Date Format: MM slash DD slash YYYY Personal or Professional ReferencesReferences cannot be a family member and must be over the age of 18.Name* First Last Phone*Relationship*Name* First Last Phone*Relationship*Name* First Last Phone*Relationship*Please answer the questionsHave you ever been charged with or convicted of a felony?*YesNoHave you ever been charged with or convicted of any crime involving a sex offense, an assault or the use of a weapon?*YesNoHave you ever been charged with or convicted of any crime involving the use, possession or the furnishing of drugs or hypodermic syringes?*YesNoAre you seeking to volunteer to satisfy court-ordered community service?*YesNoPlease explain Yes answers*I authorize and give S.E.E.K. Arizona my permission to run a background check/search on me.*YesNoI can speak Spanish.*YesNoSign Language*YesNoOther languages*Please list any special skills, hobbies or interests you may have.*SignatureI willingly submit the information on this application as current and correct. I consent to a criminal background check and the checking of my references. I understand that I am applying for a volunteer position and that if selected, I am responsible for providing additional documentation. This iframe contains the logic required to handle Ajax powered Gravity Forms.