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* MM slash DD slash YYYY Gender* Male Female Other Have a Fingerprint Clearance Card?* Yes No Fingerprint 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* MM slash DD slash YYYY Internship End Date* 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* MM slash DD slash YYYY Employed/Volunteered to* 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* MM slash DD slash YYYY Employed/Volunteered to* MM slash DD slash YYYY Reason for Leaving* Education (List current or most recent first)School* Program/Major/Degree* Attended from* MM slash DD slash YYYY Attended to* MM slash DD slash YYYY Graduation Date* MM slash DD slash YYYY School* Type of degree or diploma* Attended from* MM slash DD slash YYYY Attended to* MM slash DD slash YYYY Graduation Date* 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?* Yes No Have you ever been charged with or convicted of any crime involving a sex offense, an assault or the use of a weapon?* Yes No Have you ever been charged with or convicted of any crime involving the use, possession or the furnishing of drugs or hypodermic syringes?* Yes No Are you seeking to volunteer to satisfy court-ordered community service?* Yes No Please explain Yes answers* I authorize and give S.E.E.K. Arizona my permission to run a background check/search on me.* Yes No I can speak Spanish.* Yes No Sign Language* Yes No Other 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.