Internship Application If you are a human and are seeing this field, please leave it blank. Personal Information Fields marked with an * are required First Name * Last Name * Email * Phone * Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Cell Phone If necessary, best time to call you at home is Do you have a valid New York State Driver’s License? * YesNo For internships involving direct work with youth, you may be asked to help control or restrain the aggressive behavior of an emotionally disturbed youth. Would you be comfortable in this situation, and physically able to handle this behavior, after being fully trained? * YesNo If no, please explain Have you ever been convicted of a crime? * YesNo Are you legally eligible for employment in this country? * YesNo Have you ever been employed here before? * Have you submitted an application here before? * I am applying for FallSpringSummer Start Date * End Date Hours needed per week Current Education Fields marked with an * are required Current College/University * Area of study/major * What year are you in? * Hours needed per week * College/University Contact Name College/University Contact Phone Number Previous Education School Years Graduated Degree/Diploma Major Minor School Years Graduated Degree/Diploma Major Minor Employment History Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comment section below. Employer (Most Recent) Job Title Summarize the type of work performed and job responsibilities Dates employed Address 1 Address 2 Supervisor Name and Title Phone Reason for leaving May we contact for reference? Yes No Later Employer 2 Job Title Summarize the type of work performed and job responsibilities Dates employed Address 1 Address 2 Supervisor Name and Title Phone Reason for leaving May we contact for reference? Yes No Later Employer 3 Job Title Summarize the type of work performed and job responsibilities Dates employed Address 1 Address 2 Supervisor Name and Title Phone Reason for leaving May we contact for reference? Yes No Later Internship Information What days/times of the week are you available to complete your internship hours? Monday please indicate available hours here Tuesday please indicate available hours here Wednesday please indicate available hours here Thursday please indicate available hours here Friday please indicate available hours here Saturday please indicate available hours here Sunday please indicate available hours here Department/Program Area Requesting (check all that you are interested in) ClinicalSocial WorkHuman Services (Residential)Substance Abuse ServicesRecreationHuman ResourcesInformation TechnologyBusinessAccountingQuality AssuranceResearch Are there special requirements of the Internship Field Supervisor? (including specific licensures, example: LCSW) References Fields marked with an * are required List name and telephone number of two references who are NOT related to you. First and Last Name * Reference's Phone Number * Years Known * First and Last Name * Reference's Phone Number * Years Known * Additional Information List special accomplishments, publications, awards, etc. (Exclude memberships which would reveal race, creed, national origin, religion, age, disability, marital status, orientation or citizenship status) List any additional information you would like us to consider. Submission Page Fields marked with an * are required I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer’s service, whenever it is discovered. I give the employer the right to contact and obtain information from all references, employers, educational institutions and otherwise verify the accuracy of the information obtained in the application. I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons corporations or organization for furnishing such information. The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as required by law. This application does not constitute an agreement or contract for employment for any specific period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand that if I am employed, a criminal conviction clearance may be done as required by Social Services Law. I understand that although this Agency makes every effort to accommodate individual preferences, the nature of our program may involve a work schedule other than Monday-Friday. I understand that a medical examination is required by Social Services Law for all employees. I understand that it is this Agency’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I represent and warrant that I have read and full understand the foregoing and seek employment under these conditions. I agree to the terms above. * Upload Resume Upload Applicable Documents from College/University 1 + 1 = * It may take a minute to process the form. Please only press the submit button once. A success message will appear and you will also receive a copy of the application. Thank you!