WomensInterculturalCenter

InternshipProgramApplication

A.PersonalInformation
Name:_____________________________________

Email:______________________________

Phone#1:__________________________________

Phone#2:___________________________

CurrentMailingAddress:_______________________________________________________________

P.O.Box/Street

Whatistheeasiestwaytoreachyou?

Email

City

State

ZipCode

Phone#1 Phone#2

EmergencyContact:___________________________________________________________________

Name

Phone

Relationship

Areyouover18yearsold? Yes No
Thefollowinginformationisusedforstatisticalreportingpurposesonly.

AgeGroup:

1824

Ethnicity:

AfricanAmerican Asian
White

2544

4559

60andover

Hispanic/Latino

NativeAmerican

Other

B.EducationalandWorkBackground

1.Whatcollege/universityareyoucurrentlyattending?______________________________________

2.YearinCollege:FreshmenSophomoreJuniorSeniorOther

Graduatestudent:Specifyyearanddegreeprogram____________________________

3.Whatisyourmajorand/orcareergoal?_________________________________________________

4.Pleaseattacharesumelistinganytrainingandpaid/volunteerworkexperience.Eachentrymust
includethenameoftheemployer/organization,thelocation,startandenddates,hoursworkedper
week,jobtitle,andprimaryduties.

5.Pleasedescribeyourlanguageskills.Usethefollowingscale:No=noknowledge;Basic=can
understandandusesimplevocabularyandshortsentences;Proficient=canhaveaconversationand/or
readbasicdocuments;Fluent=canconverseonmostoralltopics,cantranslate,canreadand/orwrite
professionally.


Language
English

Speaking/Listening Reading/Writing Canyouteachthislanguagetoothers?

YesNo

Spanish

YesNo

Other

YesNo

_______________

C.InternshipInformation

1.Whichsessionareyouapplyingfor?

2.Whichinternshipareyouapplyingfor?

Fall

Spring

ESLInstruction

Marketing&ResourceDevelopment

Summer

ConsciousnessRaising

CommunityLeadershipDevelopment

MentalHealthCounseling[Masters,SpecialistinEducation,orDoctorallevelstudentstatus

(ingoodstanding)incounselingrelatedfieldrequired]
YesNo
3.Areyouworkingwithyourschooltogetcoursecreditforthisinternship?
Ifyouwantcoursecredit,itisyourresponsibilitytounderstandandmeetyourschoolsrequirements.
Wewillcompletepaperworkthatrequiresourassistanceinatimelymanner.Internsareexpectedto
prioritizetheirinternshiptimeandresponsibilitiesattheCenterwhetherornotitisforcredit.

4.ESLInstruction,ConsciousnessRaising,Marketing&ResourceDevelopment,andCommunity
LeadershipDevelopmentinternshipsaregenerally2030hoursperweek,butcanbearrangedtomore
closelymeetyourschoolsrequirements.MentalHealthCounselinginternshipsareatleast8hoursper
week(onefulldayortwohalfdays).
Howmanyhoursperweekdoyouexpecttointern?_________________________________________

5.ESLInstruction,ConsciousnessRaising,Marketing&ResourceDevelopment,andCommunity
LeadershipDevelopmentinternsareexpectedtobeavailablefortheentireinternshipperiod(Fall
Aug.15Dec.15,SpringJan.8May8,SummerMay20Jul.31).Ideally,MentalHealthCounseling
internswillbeavailablefortwointernshipperiods.Doyouhaveanytimeconflictsduringthe
internshipperiod(s)thatyouareapplyingfor?Ifso,whatarethey?____________________________

6.Willyoubebringingavehicle? YesNo
Ifnot,whatisyourplanfortransportationwhileyouarehere?PleasenotethattheAnthonyareadoes
nothaveaccesstopublictransportation.__________________________________________________

YesNo
7.Willyouneedassistanceinlocatinghousinginthearea?

D.ShortAnswerNarrative
Thefollowingquestionswillhelpusgettoknowmoreaboutyouandhowyouthinkthataninternship
attheWomensInterculturalCenterwillsupportyoureducationalandcareergoals.Pleasetypeyour
answersonaseparatepage.Donotexceed2typedpagesforallquestionsinthissection.

1.WhyareyouapplyingforthisspecificinternshipattheWomensInterculturalCenter?Howdoyou
believethatthislearningopportunitycansupportyoureducationalandcareergoals?

2.Pleasedescribeanexamplefromyoureducational,professional,orpersonalexperiencewhereyou
hadtoreevaluatealongheldbelieforidea.Howdidthiscomeaboutandhowdidthisexperience
change(ornotchange)yourviews?

3.Whatisyourperspectiveonimmigration?Ifyouarenotfromtheborderregion,whatdoyou
expecttolearnabouttheareainyourtimehere?Ifyouarefromtheborderregion,howdoesbeinga
borderresidentinfluenceyourlife?

4.Answeronlyifyouareplanningtodoanindependentresearchprojectduringtheinternship.
Brieflysummarizeyourresearchquestionsandhowyouareplanningtogatherdatatoanswerthose
questions.WhydoyouwanttoselecttheCenterasyourresearchsite?Willyourschoolrequireyou
toseekIRBapprovalforthisresearch?Howwillyoushareyourresearchandyourfinalreportwith
Centerandthelocalcommunity?PleasenotethatanyresearchproposalsthatasktheCenterto
facilitateaccesstoCenterstafforparticipantswillrequireapprovalfromtheWomensIntercultural
CenterManagementTeamPRIORtograntingaccess.

5.AnsweronlyifyouareapplyingfortheMentalHealthCounselinginternshipposition.
Howdoyouthinkyoumaybeabletoimpactthecommunitymemberswithwhomyouwork?Howdo
youbelieveyoumightlearnandgrowfromyourexperienceworkingwithcommunitymembers?
Pleasebrieflydiscussyourtheoreticalapproachtothecounselingrelationshipinyourresponse.

E.References

ESLInstruction,ConsciousnessRaising,Marketing&ResourceDevelopment,andCommunity
LeadershipDevelopmentinternshipapplicantsareaskedtosubmittwo(2)referenceletterswiththeir
applicationpacket.Onereferenceshouldbefromateacherormentor.Theothershouldbefrom
someonewhohassupervisedyouineitherpaidorvolunteerwork.Theseareprofessionalreferences;
pleasedonotsubmitreferencesfromfamilymembersorpersonalfriends.

Teacher/MentorReference:____________________________________________________________
SupervisorReference:_________________________________________________________________

MentalHealthCounselinginternshipapplicantsareaskedtosubmittwo(2)referenceletterswiththeir
applicationpacket.Onereferenceshouldbefromaninstructorfromtheapplicantsgraduate
program.Theothershouldbefromsomeonewhohassupervisedtheapplicantsworkinacommunity
setting.Inaddition,applicantsshouldsubmitabriefletterofreadinessfromtheirtrainingdirector.
Thislettershouldindicatetheirprevioussupervisedcounselingexperience(s)andtheirreadinessto
takeonamentalhealthcounselinginternshipattheWomensInterculturalCenter.

InstructorReference:_______________________________________Contactnumber:_____________
TrainingDirectorReference:_________________________________Contactnumber:_____________
LetterofReadinessReference:_______________________________Contactnumber:_____________

MentalHealthCounselinginternshipapplicantsmustalsoprovidethename,title,andcontactnumber
ofthelicensedmentalhealthprofessionalthatwillbeprovidingthemwithweeklyoffsitesupervision.
Applicantsmustalsoincludethename,title,andcontactnumberoftheirpeersupervisor,ifapplicable.

Licensedsupervisorname/title:______________________________Contactnumber:_____________
Peersupervisorname/title:_________________________________Contactnumber:_____________
Supervisorsareaskedtosignbelowtoconfirmthattheywillprovidetheapplicantwithweeklyoffsite
supervisionduringthedurationoftheirinternshipexperience.

Licensedsupervisorsignature:_______________________________________Date:______________
Peersupervisorsignature:___________________________________________Date:______________

MentalHealthCounselinginternshipapplicantsmustprovidetheirAPA/ACAstudentinsurance
providernameandpolicynumber,aswellasaphotocopyofthisdocumentasproofofinsurance.

Providername/policynumber:__________________________________________________________

F.ApplicantSignature

IcertifythatthestatementsIhavemadeonthisapplicationaretrue,complete,andcorrecttothebest
ofmyknowledge.

Ifselectedforthisinternship,Iunderstandthat:
ThisisanunpaidinternshipandtheWomensInterculturalCenterprovidesnostipends,
travel/housingreimbursements,oremployeebenefitsforinterns
Anyarrangementstoreceiveacademiccreditaremysoleresponsibility
ResearchactivitiesmaynotbeconductedattheWomensInterculturalCenterwithoutprior
approvalfromtheCentersManagementTeam

IwillbeexpectedtocomplywiththeWomensInterculturalCenterVolunteerPolicies,
includingmaintainingparticipantconfidentialityduringandaftertheinternship

______________________________________

____________________________________

ApplicantSignature

Date