Cone Health
Therapeutic Recreation Services
Internship and Practicum Application
All students applying for internships must complete this application and return it with your completed application packet. You will be personally contacted after your completed application is reviewed and if. Please adhere to the following deadlines when submitting your application packet:
Spring (January) Internship/Practicum October 1st deadline
Summer (June) Internship/Practicum March 1st deadline
Fall (September) Internship/Practicum June 1st deadline
No applications will be considered if received after then established deadline.
Name Date Submitted
University presently attending
Home phone University phone
Home address
University address
University Internship Supervisor Phone #
Desired date of Internship/Practicum
Please rate your experience in the areas listed below using the following scale. Feel free to use more than one rating to detail your experience as necessary:
1= No Experience 2=Class Experience 3=Personal Experience 4=Volunteer or Work Experience
Disability Groups
q Amputees
q Brain Injuries
q Spinal Cord Injuries
q Stroke
q Developmental Disabilities
q Diabetes
q Hearing Impaired
q Visually Impaired
q Sickle Cell Disease
q Cancer
q Adults
q Children
q Geriatrics
Adaptive/Leisure
q Bowling
q Wheelchair Sports (specify)
q Needlework
q Gardening
q Aquatic Therapy
q Water Sports (specify)
q Snow Sports (specify)
q Special Olympics
q Paralympics
q Sensory Stimulation
q Infant Stimulation
Other Leisure
q Crafts
q Dance
q Humor Therapy
q Leisure Education
q Music (specify)
q Medical Play
q Pet Therapy
q Reality Orientation
q Cooking Therapy
Documentation
q MDS
q DSM IV Criteria
q Medical Terminology
q Abbreviations
Mental Health Treatment Interventions
q Stress Management
q Self-Esteem
q Patient Intervention
q Relaxation Training
q Other Experience (specify)
Please answer the following questions briefly and completely:
1. Briefly summarize your experience using recreation as a form of therapy. Include length of time, age levels, types of populations, etc., and any other fieldwork experiences you have completed.
2. What are your areas of strength in recreation and group process? List two goals you might work toward to improve.
3. What are your areas of growth opportunities in recreation and group process? List 2 goals you might work toward to improve.
4. Describe experience planning large group activities.
5. Summarize your personal strengths and weaknesses.
6. Why do you want to complete fieldwork at Moses Cone?
7. What facets of therapeutic recreation interest you the most (including modalities, populations, etc.)?
8. What facets of therapeutic recreation interest you the least?