Internship Questionnaire

Internship Questionnaire
Surname
Name
Gender
Date of Birth

DíaMesAño
Place of Birth
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Citizenship
University and Academic Major
Email
Your service placement is determined by your interests, skills, and goals, and by the needs of the community. Please rank your preferences with (1) as your first choice.
Type of people you would like to work with

Young ChildrenAdolescentsAdultsElderlyMentally ChallengedPhysically Challenged
Type of service you would like to do

TeachingHealthcareRecreationArts*Others*
Why did you choose the ones you did?
What would you consider to be the ideal service placement?
Indicate special skills and interests that you may have
Please list work and/or community service experience
Place
From

DíaMesAño
Fecha
Until

DíaMesAño
Fecha
Paid
Response to the following is optional, but may be helpful in making a service placement
Religious Affiliation
Are you an active member?
Previous Experience
Travelling Experience
Personal Experience
Personal goals
Professional goals
Extra curricular activities
Interests
Expectations about this experience
About Myself
Reference
First name
Last name
Work place
Position
Relationship
Phone
Email
Ideclare that I have answered all questions in this questionnaire fully and truthfully. I further agree to abide by the guidelines and regulations of UEES

Chek
Date

MesDíaAño
Signature of Applicant
Should be Empty:

Please list work and/or community service experience