UNIVERSE KONADU Artistpreneur™ Academy for Emerging Leaders
Interns Placed with UK - L.adies I.ndependently T.hriving
Organization Information
Name of Organization
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Name of Person Completing Form (first & last, include title)
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Entity Type
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Please check all that apply to your organization
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Has a current copy of its Certificate of Liability Insurance
Worked with placing interns in the past
Serves youth
Offers transportation for interns
Has a physical office location
Offers intervention & preventative services
Has Criminal Background Check on file for intern
Please provide a current copy of your Certificate of Liability Insurance
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Organization's Physical Address
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Organization's Mailing Address
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Main Office Number
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Format: (000) 000-0000.
Point of Contact (first & last name, include title)
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Point of Contact Office Number (include extension)
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Extension
Point of Contact Mobile Number
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Point of Contact Email
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example@example.com
Internship Information
Area(s) of Interest(s) for Placements
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Anticipated Start Date
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Month
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Day
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Date
Hour Minutes
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PM
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How will the students benefit from being placed as interns with Universe Konadu?
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How will the organization benefit from students being placed as interns with Universe Konadu?
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Additional Comments and Information
By choosing yes below and submitting this form, you agree that you are an authorized agent/representative of the above named organization; you agree to the above named organization's participation in the above named program as Program Partner; you agree to allow interns of the above named program to serve in the respective role specified in Position Title; you agree that interns placed will only serve in the capacity outlined in the Position Description and hereby release UNIVERSE KONADU and its legal representatives and assigns from all claims and liability relating to said program.
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