Internship Application

Name(Required)

First Last

Date of Birth(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Driver’s License Number(Required)

Do you have access to a car? (Required)

Yes

Name of School:

Major/Concentration:

Degree Level

Associate Degree

Bachelor’s Degree

Master’s Degree

Ph.D.

Are you pursuing licensure?

N/A

Yes

If yes, please specify:

Please describe any interest in a specific area of the HCSO or specialty area (i.e. mental health, recovery, female offenders)

During which semester(s) or month(s) are you seeking to fulfill your internship hours?

How many total internship hours are required?

Do you have a proposed schedule for your internship hours or do you have any scheduling limitations?

Please describe any further supervision requirements:

Please provide the name and contact number of your school’s fieldwork coordinator/academic advisor:

Supporting Documents

Max. file size: 2 MB.