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 SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Pronouns*EDUCATIONCurrent School:*Major/Program:*Expected Date of Graduation:* Previous School:Major/Program:Date of Graduation: 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 : HH MM AM PM Monday End Time : HH MM AM PM Tuesday Start Time : HH MM AM PM Tuesday End Time : HH MM AM PM Wednesday Start Time : HH MM AM PM Wednesday End Time : HH MM AM PM Thursday Start Time : HH MM AM PM Thursday End Time : HH MM AM PM Friday Start Time : HH MM AM PM Friday End Time : HH MM 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?*YesNoIf yes, in what languages are you fluent?Do you have any experience working in a crisis situation?*YesNoIf 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?*YesNoIf 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
