2025 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

Race*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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?

Current GPA*

How many people live in your home?

Annual Household income*

yesnoChoose not to disclose

How would you like to be paid?

Direct Deposit (Routing Number)

Direct Deposit (Account Number)

Form