Internship Applicant Registration Form

Intern Application - Registration Form

Fill out the form to be considered for the Intern Opportunity
Applicant Name*

First NameMiddle Name/sSurname
Gender*
Birth Date*

MonthDayYear
Are you 18 years or older? (If under 18, parental consent will be required)*

YesNoOther
Country and City/Town where you currently live*
USA in New York
Applicant E-mail*
example@example.com

Access to Technology*

	Yes	No
Do you have access to a personal computer or laptop?
Do you have access to the Internet at home?
Can you access the Internet with a laptop?
Do you have access to Zoom or other video conferencing platforms?

Skills Assessment Table*

	None	Basic	Fair	Advanced	Expert
Microsoft Word
Microsoft Excel
PowerPoint
Google Docs/Sheets
SPSS
R / Python (data analysis)
Internet Research (Google Scholar, PubMed, etc.)
File Management (organizing and submitting documents)

Availability*

	We’d love to hear about
What dates are you available to begin the internship?
What dates are you available to begin the internship?
What date would you prefer to end?
How many hours per week are you available to work on projects? (e.g., 5, 10, 15, etc.)
Do you have any standing commitments during the internship period?

Write short description about yourself.*
Do you have any experience with statistics, data analysis, or writing reports? *
What do you hope to gain from this experience?*
Do you have a specific interest in working with or contributing to the Black community? Please explain.*
How did you hear about this internship opportunity?*
By submitting, I understand this is an unpaid, virtual, project-based internship.*

Yes
I confirm that I am submitting this application myself.*

Yes
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Intern Application - Registration Form