Safe Harbor Internship Application What internship(s) are you applying for?* Counseling and Advocacy Team Internship Program Community Outreach Internship Program Human Trafficking Shelter Internship Program Domestic Violence Shelter Internship Program Court Advocacy Internship Program APPLICANT INFORMATIONName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Pronouns*EDUCATIONCurrent School:*Major/Program:*Expected Date of Graduation:* MM slash DD slash YYYY Previous School:Major/Program:Date of Graduation: MM slash DD slash YYYY EMPLOYMENTCurrent or Most Recent EmploymentCompany:*Title:*Responsibilities:*Other Relevant Employment ExperienceCompany:Title:Responsibilities:VOLUNTEER AND INTERNSHIP EXPERIENCEVolunteer/Internship #1Company:*Title:*Responsibilities:*Volunteer/Internship #2Company:Title:Responsibilities:Volunteer/Internship #3Company:Title:Responsibilities:AVAILABILITYWhat semester(s) are you applying for?*What are the hours requirements for your practicum/internship?*What is your proposed start date and end date?*Please indicate your available hours during the week:Monday Start Time : Hours Minutes AM PM AM/PM Monday End Time : Hours Minutes AM PM AM/PM Tuesday Start Time : Hours Minutes AM PM AM/PM Tuesday End Time : Hours Minutes AM PM AM/PM Wednesday Start Time : Hours Minutes AM PM AM/PM Wednesday End Time : Hours Minutes AM PM AM/PM Thursday Start Time : Hours Minutes AM PM AM/PM Thursday End Time : Hours Minutes AM PM AM/PM Friday Start Time : Hours Minutes AM PM AM/PM Friday End Time : Hours Minutes AM PM AM/PM What are your site supervisor requirements for your practicum/internship (e.g. licensed, # of years of clinic experience, etc.)?*EXPERIENCE AND SKILLSAre you bilingual or multilingual?* Yes No If yes, in what languages are you fluent?Do you have any experience working in a crisis situation?* Yes No If yes, please give a brief description of the experience:Do you have any experience working with survivors of domestic violence, sexual violence or human trafficking?* Yes No If yes, please give a brief description of the experience:Why are you interested in interning at Safe Harbor?*Please describe your career goals.*What special skills or experiences would you bring as an intern at Safe Harbor?*PLEASE PROVIDE THREE PROFESSIONAL REFERENCES:Reference #1:Name* First Last Relationship:*Company:*Title:*Phone*Email* Reference #2:Name* First Last Relationship:*Company:*Title:*Phone*Email* Reference #3:Name* First Last Relationship:*Company:*Title:*Phone*Email* Untitled Δ
