Safe Harbor Internship Form 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{{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…