Internship Application Personal InformationWhat type of internship are you interested in?*Clinical/TherapeuticNon-ClinicalName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Phone Number (Work)Date of birth: (MM/DD/YY)* Date Format: MM slash DD slash YYYY Employer (or if full-time student, university)*Are you bilingual? If so, please specify what other languages you are fluent in*Email* Internship Interview Questionnaire:1. What led you to choose this program, and what do you hope to contribute to it?*2. Please list any background working with sexual assault survivors and/or any related volunteer experience.*3. What do you anticipate would be the most difficult part of this program for you?*4. How do you feel about working with/assisting people who are of different race, religion, belief or lifestyle than yours?*5. Have you or anyone you know been a victim of sexual assault? If yes, how long ago and what have you done to work through it?*6. We prohibit the use of mind-altering drugs and alcohol while on call. Can you agree to abide by this policy? (Yes or No) If no, please explain.*7. Are you currently on probation or parole or completing community service hours? (Yes or No) If yes, please explain.*8. Have you been arrested, charged or convicted of a crime(s), or have any charges currently pending against you? (Yes or No) If yes, please explain.*9. Are you willing to complete paperwork, keep track of services, and document all client contact? (Yes or No) If no, please explain.*10. Client confidentiality is a top priority at DARCC. Do you foresee having a problem in this area? (Yes or No) If yes, please explain.*ReferencesPlease list two people other than relatives and friends:1. Name and Phone Number:*2. Name and Phone Number:*Please list other/past related volunteer experience (include program, your position, your supervisor, and their phone number if available):* This iframe contains the logic required to handle Ajax powered Gravity Forms.
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