INTERNSHIP APPLICATION FORM

PHS Community Services Society, Vancouver, Canada

To apply for an internship, please submit a completed application form and your up-to-date resume by email to:

Be sure to include the following in the subject line of your email: PHS Internship

All applications must be followed by a nomination form, to be sent in separately by your nominator to the above email address.

The deadlines for submission are Feb 15, April 10, June 5 and July 30, 2013.

Applications are only accepted in an electronic format. Incomplete applications will not be considered.

Personal information
YOU MUST HAVE A VALID PASSPORT TO APPLY.
Citizenship:
Last name (as in passport):
First name (as in passport):
Middle name (as in passport): / Gender (as in passport):
Passport number: / Passport expiration date:
Work phone number: / Home phone number: / Mobile phone number:
Primary e-mail address:
Secondary e-mail address:
LANGUAGE SKILLS
On a scale of 1-5 (5 = fluent and 1 = very poor), please indicate your English skills in the following areas:
Reading:
Writing:
Speaking:
Comprehension:
Where do you currently work (name of organization) and what is the title of your position?
What are your primary work responsibilities?
What experience do you have abroad (business, personal, study, etc.)? Please describe.
Nominated by (please ensure that your nominator completes and files the nomination form):
Please indicate which internship dates you are applying for (you may indicate more than one option):
[ ] April 15-May 24, 2013
[ ] June 10-July 19, 2013
[ ] August 5- September 13, 2013
[ ] September 30 – November 8, 2013
Do you have a credit card or international bank account through which to receive international bank transfer?
[ ] yes
[ ] no
About the internship
1.  We are proposing the following topics of focus. Please check all that interest you:
[ ] Medically Assisted Therapy (MAT) with methadone and/or buprenorphine
[ ] Needle syringe programs
[ ] Safer injection / inhalation programs
[ ] Peer empowerment and work initiatives
[ ] Support services for survival sex trade workers
[ ] Managed alcohol programs
[ ] Drug and Alcohol detox and treatment
[ ] Community activism
[ ] Overdose prevention/naloxone
[ ] HIV testing treatment
[ ] TB testing treatment
[ ] HCV testing treatment
[ ] Case management/counseling
[ ] Supportive housing
2.  What other information, knowledge and skills you would hope to gather from an internship with the PHS?
About you:
3. Please briefly describe your experience working with people who use drugs.
4. How will the knowledge from this internship will be useful to you? How do you hope to apply what you learn when you get back home? Please give some specific details.
5. Please consider what you can bring to the internship to facilitate a knowledge exchange with your Canadian hosts. Is there a topic on which you would like to make a presentation? Or is there an activity you would like to lead? Please describe.
About your community:
6. Please describe the community in which you work and, briefly, the broader socio-political factors that impact your work.
7. In regards to your city or your community, how many active drug users are there (known or estimated)?
8. How many people are receiving Medically Assisted Therapy with methadone and/or buprenorphine? What is the proportion on methadone vs. buprenorphine?
9. What are the main legal and illicit drugs that people use?
11. On a scale of 1-5 where 1 is lowest and 5 is highest, how would you rate the following services in your community? Rate all that apply. If the service is not available, please indicate “N/A”:
[ ] Medically Assisted Therapy (MAT) with methadone and buprenorphine
[ ] Needle syringe programs
[ ] Peer empowerment and work initiatives
[ ] Drug and Alcohol detox and treatment
[ ] Overdose prevention/naloxone
[ ] HIV testing and treatment
[ ] TB testing and treatment
[ ] HCV testing and treatment
[ ] Case management/counseling
12. What are the most significant issues in relation to access to treatment and care for people who use drugs in your community? Please list and explain:
13. In your opinion, what are three things that can be done in your city and with current resources to improve quality of care make care and more it more accessible for people who use drugs?
14. Please think of a particularly challenging case from your personal experience involving a drug user who was trying to access treatment and care. In one or two paragraphs, please describe the specifics of the case, what made it challenging, what interventions were attempted by yourself and others, what worked or did not work.
15. The PHS is proud to work with individuals who have real life experience with addictions, mental health issues or have been involved in the criminal justice system. However, disclosure is essential to making internships successful. Given this, do you have any reason to believe that your history with the justice system or with addiction might impede your ability to travel to Canada? Please explain.
Statement of Understanding:
By singing below I acknowledge that if accepted into the PHS-OSF International Internship Program I am committing to:
ü  Participating full time Monday-Friday, 9am-5pm embedded in PHS programs
ü  Being available for a consecutive 6 week period to live in Vancouver
ü  Weekly check-ins with the PHS representative in Vancouver to ensure needs are being met
ü  Working with OSF and PHS representatives to arrange travel documents and travel arrangements from home country to Vancouver, Canada.
Printed Name: ______
Signature: ______
Date: ______
To support your application to the Seminar, please provide an up-to-date CV and one completed nomination form. Incomplete applications will not be considered.