Personal Information

First Name

Last Name

Phone *

Email *

Street Address

City

State

Country

Postal code

Academic Information

Are you legally eligible to work in the U.S.?

Yes

No

University/College Name

Degree Program

Year in Program

Expected Graduation Date

Internship Coordinator Name

Internship Coordinator Contact

Does your program require a formal affiliation agreement?

Yes

No

Unsure

Internship Logistics

Desired Internship Start Date

Total Hours Needed to Complete Internship

Preferred Weekly Schedule (Days/Times Available)

Are you seeking clinical or non-clinical placement?

Experience & Interests

Have you had previous internship or practicum experience?

Yes

No

If Yes, Briefly Describe

Do you speak a second language?

Please upload the following:

CV/Resume

Cover Letter

Academic/Professional Reference