Internship Application
Please answer the following questions about your personal history. This information is required to comply with our data entry system. Some questions are asked for placement and will not affect your application status but are essential for a thorough evaluation. Family Service Agency considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
General Information
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Preferred Pronouns
Date of Birth
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Month
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Day
Year
Date
What language(s) do you primarily use?
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English
Spanish
American Sign Language
French
Arabic
Polish
Other
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
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Internship, Employment, & Student Status
What internship are you applying for?
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Community Support (undergraduate)
School-Based & Youth Programming (undergraduate & graduate)
Community Outreach (undergraduate)
Children's Advocacy Center (undergraduate & graduate)
Center for Counseling (graduate)
Summer Camp (undergraduate & graduate)
Are you required to have an internship?
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Yes
No
Other
How many hours per week will be dedicated to your internship?
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Approximate answers are okay!
Anticipated internship length (ex: August 2023-December 2023)
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Have you had an internship previously?
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Yes
No
Other
What college or university are you attending?
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What kind of program are you studying within?
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Associates
Bachelors
Masters
Other
Please list your major(s), minor(s), certificate(s), etc.
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Are you currently employed?
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Yes
No
If you are currently employed, where do you work, what is your job title, and how many hours do you work per week?
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Background
Please note: answers will not necessarily disqualify a person's eligibility to participate in volunteering. Volunteers are subject to various background checks.
Have you ever been convicted of a felony or misdemeanor, including DUI? (This would not include minor traffic violations or a case that has been expunged, sealed, dismissed, erased, or pardoned)
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Yes
No
If you answered yes, please explain:
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Character References
Personal References include relatives, friends, roommates, etc. Professional References include supervisors, professors, managers, etc. Reference 3 can can either Professional or Personal.
Personal Reference 1
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First Name
Last Name
Personal Reference 1 Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Personal Reference 1 Email
example@example.com
How long have you known Reference 1 and in what capacity?
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Professional Reference 2
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First Name
Last Name
Professional Reference 2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Professional Reference 2 Email
example@example.com
How long have you known Reference 2 and in what capacity?
*
Reference 3
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First Name
Last Name
Reference 3 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3 Email
example@example.com
How long have you known Reference 3 and in what capacity?
*
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Vehicle
Do you own a vehicle?
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Yes
No
If you own a vehicle, what is the YEAR, MAKE, and MODEL?
If you own a vehicle, what is the License Plate Number?
If you own a vehicle, do you have insurance?
Yes
No
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Resume
Upload your resume here or send it via email to rlouckskues@fsadekalbcounty.org
Browse Files
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Submit
By submitting this document, you attest that the information provided is factual.
Signature
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