Internship/Practicum Application

Internship/Practicum Application
All individuals interested in an INTERNSHIP OR PRACTICUM with
Hilma's Heart Community Organization, Inc. must complete this application in full.

Items marked with an asterisk require a response.
Profile Information
Full Name*

First NameLast Name
Gender*

MaleFemale
E-mail*
example@example.com
Phone Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Information
Are you authorized to work in the United States?*

YesNo
Which of the following are you interested in? (select all that apply)*

InternshipPracticum
How did you hear about this opportunity with the Hilma's Heart?:*
Have you previously been employed or previously served as an intern or practicum student?*

YesNo
If yes, please list the date(s), organization(s), and position(s) held:
If you are using this internship for practicum or internship credit, please provide the following details:
Course name and number:
School/University:
Instructor's name and contact information (if applicable):
Availability
Please select the semester(s) you would like to fulfill your hours:*

FallSpringSummer

How many hours are required to fulfill your internship/practicum requirements?
Fall Semester - # of Hours Required
Spring Semester - # of Hours Required
Summer - # of Hours Required

Fall Semester Availability:

Summer Availability: What is your availability or desired days/times to work? (select all that apply):

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
8am-9am
9am-10am
10am-11am
11am-12pm
12m-1pm
12pm-1pm
1pm-2pm
2pm-3pm
4pm-5pm
6pm-7pm
7pm-8pm

Spring Semester Availability:

Fall Semester Availability: What is your availability or desired days/times to work? (select all that apply):

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
8am-9am
9am-10am
10am-11am
11am-12pm
12m-1pm
12pm-1pm
1pm-2pm
2pm-3pm
4pm-5pm
6pm-7pm
7pm-8pm

Summer Availability:

Spring Semester Availability: What is your availability or desired days/times to work? (select all that apply):

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
8am-9am
9am-10am
10am-11am
11am-12pm
12m-1pm
12pm-1pm
1pm-2pm
2pm-3pm
4pm-5pm
6pm-7pm
7pm-8pm

Disclaimer:

At this time, we offer unpaid opportunities. As we build our funding, in the future we plan to offer stipends and paid opportunities. If this does not work for you at this time, we understand and would value keeping your application on file for future opportunities.
At this time, we offer unpaid opportunities. Are you still interested in this internship/practicum?*

YesNot at this time, please keep my application on file for future paid opportunities.Other (please specify)
Affidavit of Criminal History

*Prospective volunteers, interns, and practicum students must disclose any history of criminal violations if they occurred after the employee or volunteer reached the age of 18 years old. Violations that occurred prior to the age of 18 years old must be disclosed if they are public information.
Do you have any pending or past criminal violations?*

YesNo
If yes, please explain:
FINGERPRINTING

All volunteers, interns, and practicum candidates are required to be fingerprinted for a criminal background check. (Hilma's Heart will cover the fees for your fingerprinting and criminal background check).
Due to the nature of this opportunity, if selected to serve with Hilma's Heart, a background check required. Do you authorize a background check?*

YesNo
General Questions
Why do you want to take part in Hilma's Heart Internship/Practicum Program? How does it fit into your personal goals now, and your future career goals?*
What specific goals are you hoping to accomplish during your internship/practicum? Are there certain areas you would like to focus on?*
*Optional: Is there any other additional information that you would like to share with us? Are there any qualities that you possess that were not addressed in this application that you feel are important to share?
Educational Background

List the schools you have attended, beginning with the most recent
Are you currently enrolled in school?*

YesNo

1st School Information
Name of School/University:
Program/Major:
GPA:
Graduated:

YesNo
Entry Date

MonthDayYear
Date
Graduation Date or Expected Graduation Date

MonthDayYear
Date

2nd School Information
Name of School/University:
Program/Major:
GPA:
Graduated:

YesNo
Entry Date:

MonthDayYear
Date
Exit Date

MonthDayYear
Date

3rd School Information
Name of School/University:
Program/Major:
GPA:
Graduated:

YesNo
Entry Date:

MonthDayYear
Date
Exit Date:

MonthDayYear
Date

Training and Additional Information
Training and Additional Information
Other education / training / skills:
Computer skills (hardware and software):
Current professional licenses / certifications / registrations:
Current professional licenses / certifications / registrations:

Applicant Documents
CV/Resume*

Cancelof
Cover Letter (*Optional)

Cancelof
Professional References

Please provide a minimum of two (2) professional references. (One reference must be from your current university).
Name*

First NameLast Name
Relationship*
Employer*
Job Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name*

First NameLast Name
Relationship*
Employer*
Job Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Employer
Job Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
I certify that all statements made on this application and the information contained in all other documents I have submitted in support of my application are true and complete to the best of my knowledge. I understand that the Hilma's Heart Community Organization staff may verify the information I have furnished.

I understand and agree that any misrepresentation, omission, or falsification of information provided constitutes grounds for rejection and may disqualify me from further internship/practicum opportunities at the Student Success Center.

I authorize the Hilma's Heart Community Organization to make inquiries regarding my education, work experience, references, and criminal history. I understand that any internship/practicum offer may be conditioned on the University's receipt of a satisfactory background inquiry. I agree to cooperate in such inquiry and understand that providing misleading information may result in disqualification and/or termination.

By electronically submitting this application, I certify that I have read and agree with these statements and conditions.
By electronically submitting this application, I certify that I have read and agree with these statements.
Signature*

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Name*

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Internship/Practicum Application

Profile Information

General Information

If you are using this internship for practicum or internship credit, please provide the following details:

Availability

Disclaimer:

Affidavit of Criminal History

FINGERPRINTING

General Questions

Educational Background

Training and Additional Information

Applicant Documents

Professional References