Practicum Student/Internship Application
This application is only for students applying for a practicum or internship at Region 9. If you are looking for our employment application, please visit our employment page at rec9nm.org for the link.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Current City and State of Residence
*
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Name of University
*
Degree/Major
*
Name and e-mail of the practicum/internship contact at your university
*
Anticipated graduation date (mm/yyyy)
*
School year of practicum/internship
*
Semester of practicum/internship required
*
Fall
Spring
Full Year (Fall & Spring)
Minimum hours per week of direct supervision
*
Minimum hours per week for placement
*
Current GPA
*
Please list 3 recent classes you have taken that most relate to this internship/practicum
*
What are your professional goals?
*
0/0
Is this a required internship/practicum?
*
Please Select
Yes
No
Do you have a background check from an educational entity dated within the past 12 months?
*
Please Select
Yes
No
Are you willing to use your own vehicle to travel?
*
Please Select
Yes
No
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Acknowledgement of Application Accuracy: I certify that all answers given by me are true, accurate and complete. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying documents) will be cause for denial of practicum/internship or immediate termination of practicum/internship, regardless of when or how it was discovered.
By signing you agree and understand the acknowledgement above
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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