Community Health Internship

Coburn Place InternshipApplication

Date: ______

Full Name: ______

Contact Phone Number: ______Email Address: ______

Name of University Attending: ______

Major: ______

Semester Desired: ______

Hours Needed: ______

Days and hours of availability: ______

Internship forms/requirements attached? Yes ______No ______

Please complete the following questions in detail. Use additional sheets of paper, if needed.

How did you hear about Coburn Place? ______

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Why are you interested in completing an internship at Coburn Place? ______

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Have you had any training or coursework on domestic violence? Please explain.

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What areyour personal and school-related goals for your internship?

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What would you like to accomplish at Coburn Place during an internship, if one was approved?

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List activities involved with, areas of interest and special skills: ______

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List any limitations to performing duties or if accommodations are requested: ______

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Emergency Contact (Name, phone number, address, email): ______

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List one academic and one personal/professional reference. Please include name, phone number,email,

address, professional position, relationship with that person, and length of time known.

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Please attach a copy of your resume with this application.

Please read carefully before signing.

Coburn Place is an equal opportunity employer. Coburn Place does not discriminate in its selection of internship candidates on account of race, color, religion, national origin, citizenship status, age, gender, sexual orientation, military service veteran status or any other protected class as defined by state and federal law. Coburn Place will comply with its obligation to provide reasonable accommodation to qualified individuals with disabilities.

I understand that neither the completion of this application nor any other part of my consideration for an internship establishes an obligation for Coburn Place to select me for their internship program. If I am selected, I understand that either Coburn Place or I can terminate the internship at any time for any reason, with or without cause and without prior notice. I understand that no representative of Coburn Place has the authority to make any assurance to the contrary other than the Executive Director.

I attest with my signature below that I have given to Coburn Place true and complete information on this application. No requested information has been concealed. I authorize Coburn Place to contact references provided for internship reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for denial of an internship opportunity and /or immediate dismissal.

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Printed Name of Intern Candidate Signature of Intern Candidate

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Date

Updated 7/5/2011, 10/14/2011, 10/19/2011

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