Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you 18 year of age or older? *

Yes

No

When would you be able to start? *

MM

DD

YYYY

DARCC requires interns to commit to at least one semester, which is a combination of on-call and in-person office hours. Advocacy interns are also required to respond to medical accompaniment calls with any of DARCC's affiliated hospitals during assigned shifts. You are required to provide your own transportation. Can you make this commitment? If you have any concerns, please specify. *

Yes

No

Other

I am seeking an internship for the... *

Fall Semester

Spring Semester

Summer Semester

Have you ever received services from DARCC?* *

Yes

No

Unsure

DARCC requires interns to have liability insurance through their university and/or personal liability insurance. Is this something you can agree to?* *

Yes

No