Internship Applicant Registration Form

Prairie View Internship/Student Learner Application

Fill out the form to be considered for a student learning opportunity.
Applicant Name*

First NameMiddle Name/sSurname
Applicant E-mail*
example@example.com
Applicant Mobile Number*
Gender*
Birth Date*

MonthDayYear
Which pronouns do you prefer to use?*
Do you currently work at Prairie View?*
Have you ever worked at Prairie View?*
Have you ever received services from Prairie View?*
If so, at what location did you receive services? (If not, write NA)*
Has a family member ever received services from Prairie View?*
College/University Attending:*
Major/Discipline:*
Graduation Date:*
Which degree are you pursuing?*
Post Grad License:*
What kind of internship are you seeking?*
# of total on-site hours needed?*
# of direct hours needed?*
# of non-direct hours needed?*
What are the requirements of your internship program? (If you have a document explaining the requirements, please email it to toneynm@pvi.org.)*
What credentials are required of your supervisor?*
Name of school overseeing internships? Email address and Phone number?*
Is there a specific Prairie View department/person you have already been in communication with regarding an internship?*
If yes, Please list Name or Dept of Prairie View contact:*
Do you plan on living in the Newton/Wichita/McPherson County/Marion County/Harvey County area during your internship?*
Do you plan on living in the Newton/Wichita/McPherson County/Marion County/Harvey County area following graduation?*
Tell us about yourself. (You may attach a separate sheet.).*
What are your plans following graduation?*
How long would you like your internship to last? (Start date to end date)*
What is your availability to work on a normal week?

Monday morningMonday afternoonTuesday morningTuesday afternoonWednesday morningWednesday afternoonThursday morningThursday afternoonFriday morningFriday afternoon
*Please email your resume and cover letter to toneynm@pvi.org.
Should be Empty:

Prairie View Internship/Student Learner Application

*Please email your resume and cover letter to toneynm@pvi.org.