2024 MCD PAID INTERNSHIPS

Name

First NameLast Name

Who is your Michigan Rehabilitation Counselor?

Date Of Birth blanks

Must be 14-26 years old as of July 1st 2024

Social Security Number* Please enter the applicant’s actual Social Security Number. MCD will validate your entry therefore random numbers will not be accepted.

Students Phone Number

Please enter a valid phone number.

Gender*

Email

example@example.com

Orgin*

Race*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Which area do you desire to work in? (section is likely but not guaranteed)

Parent/Guardian Name* blanks

Parent/Guardian Phone Number* blanks

Parent/Guardian Email address blanks

Emergency Contact Name* blanks
Emergency Contact Email* blank
Emergency Contact Phone Number* blanks

Emergency Contact Relationship

What level of school are you in?

Highest Grade Level Completed

Current GPA*

How many people live in your home?

Annual Household income*

Do you or your household receive TANF (Cash Assistance) Benefits *:

yesnoChoose not to disclose

Do you or your household receive SSI Benefits *

yesnoChoose not to disclose

Do you or your household receive Food Assistance (SNAP)

yesnoChoose not to disclose

Are you currently Expecting or a Parent *:

yesnoChoose not to disclose

Are you homeless?*

yesnoChoose not to disclose

Are you currently in foster care?*

yesnoChoose not to disclose

Are you behind a grade level?*

yesnoChoose not to disclose

Are you disabled?*

yesnoChoose not to disclose

If yes, what type of assistance do you need?*

What area of Detroit would you prefer to work in? (please note your selection is not guranteed)

How would you like to be paid?

Direct Deposit (Routing Number)

Direct Deposit (Account Number)

Form