Internship Application Please fill out this form if you’re interested in interning with Second Story! Asterisk “*” indicates required field "*" indicates required fields Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email* Daytime Phone*Are you 18 or older?* Yes No Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?*--SELECT ONE--Friend, community member, or word of mouthDrove by and saw your signI received services from the organizationOnline or social mediaNewspaper, radio, or print materialsI'm not really sureWhat languages do you speak? What times each week are you available to intern?* Monday through Friday, 9 AM - 5 PM Monday through Friday, 8 AM - noon Monday through Friday, noon - 4 PM Monday through Friday, 4 PM - 6 PM Monday through Friday, 6 PM - 8 PM Monday through Friday, 8 PM - 10 PM Saturday and/or Sunday, 8 AM - noon Saturday and/or Sunday, noon - 6 PM Saturday and/or Sunday, 6 PM - 10 PM This is intended to give us a rough idea of your availability, so the times don't need to be exact. What special skills, talents, or work would you like to share with us? How often and for how long are you available to intern?* How would you like to participate? Please give us more information.Have you had other experiences relevant to this internship? What did you do?What limitations should we know about?What do you hope to learn from this experience?*What else would you like us to know about you?Internship Information: How many hours do you need and in what semester?*Internship Information: What are your supervision requirements?*Internship Information: What are your learning objectives and goals for this internship?*ReferencesPlease provide three people who have known you for at least three years and are willing to serve as references.Reference #1Reference #1 - Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last What is your relationship to Reference #1?* Reference #1 - Phone*Reference # 1 - Email* Reference #1 - Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference #2Reference #2 - Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last What is your relationship to Reference #2?* Reference #2 - Phone*Reference # 2 - Email* Reference #2 - Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference #3Reference #3 - Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last What is your relationship to Reference #3?* Reference #3 - Phone*Reference # 3 - Email* Reference #3 - Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Security and Background Checks* I agree with the following: I understand that if I am selected for a volunteer or intern position that involves working with youth directly, I will be required to undergo a background check. I understand that if I must undergo a background check, I am responsible for the $60 fee. Second Story staff will notify you in advance of any costs and will keep you fully informedKeep in touch with Second Story!* Yes, please send me program updates and stories about Second Story's young people! No, please do not add me to your email list. EmailThis field is for validation purposes and should be left unchanged.
