Intern Application

Name*
First Middle Last
Date of Birth*
Local Address*
Street Address Address Line 2 City State ZIP Code
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Email*
Occupation and Job-Related Skills*
Employer and/or School Year*
Educational Background*
Other Training*
Other Volunteer Experience*
Business Address
Street Address Address Line 2 City State ZIP Code
Business Phone
It is OK to contact me at work.
It is NOT ok to contact me at work.
Business Hours
How long have you been employed?
Do you own a reliable car? If yes, do you have insurance?*
Hobbies, Clubs, Areas of Interest*
What intern position are you applying for?*
How did you hear about the WRCNRV and the internship program?*
Do you sincerely feel you can meet the minimum of at least 8 hours per month interning?*
Do you sincerely think you will be able to work evenings?*
Do you sincerely think you will be able to work on weekends?*
Do you authorize the agency to check with appropriate public authorities (e.g. police, courts, motor vehicle department, etc.) for matters of public record regarding your background of history?*
Have you ever been convicted of a crime?*
If yes, what crime(s) have you been convicted of?
Have you ever applied to become a WRC volunteer or intern before?*
If yes, for what position and when did you apply?
References
Please list the names and addresses of three (3) persons who can vouch for your character and who have known you for at least one (1) year (including employer). Please do not use family members.
Reference #1 Name (Professional)*
First Last
Relationship to you*
How long known*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
What is the best way to contact them?*
Reference #2 Name (Professional)*
First Last
Relationship to you*
How long known*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
What is the best way to contact them?*
Reference #3 Name (Professional or Personal/Character)*
First Last
Relationship to you*
How long known*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
What is the best way to contact them?*
Permission For Release Of Information For Intern Reference Checks*
I hereby grant permission for the above-named individuals and/or agencies to release information to the Women’s Resource Center concerning my character, employment, performance, skills, competence, and/or general ability. It is understood that this permission includes cumulative and confidential information which would assist the Women’s Resource Center in filling internship positions.
Intern Policy*
The Women’s Resource Center is an agency designed to provide resources and services to women in crisis; particularly, victims of domestic violence and sexual assault. In determining whether an applicant may be considered to fill an intern position, due consideration must be given to those past and present factors in the health, personality, and behavior of each individual which professional agency personnel deem, under any circumstances, may have a significant effect upon intern’s performance within our agency and which, if revealed at a later date, may affect the agency and/or its clients adversely. The undersigned acknowledges and agrees that (1) he/she is not obligated, if called upon, to perform intern services herein applied for and that the agency is not obligated to assign or actively seek to assign him/her with an intern position and (2) as part of the agency’s screening process, additional personal information will be elicited from the applicant by professional agency personnel.

References