I.
| Contact Information
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| | First Name: | | Date: | |
| | Last Name: | | | |
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| | Address: | |
| | Home Phone: | | | |
| | Best Time To Call: | | | |
| | Email: | * required |
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| | Emergency Contact: | |
| | Relationship: | |
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| | References: (only one may be a relative; list names, phone number w/area code, and email address) |
| | 1. | 2. |
| | 3. | |
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II.
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Education
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| | School: | |
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Degree: |
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| Major: | |
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Graduate Student?
Yes
No |
| | Semester and year of desired internship: |
| | What are your plans after the internship is completed?
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III.
| Are you able to complete your internship during the hours of?
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8:00 am – 4:30 pm Monday – Friday?
Yes
No |
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11: 00 am– 7:30 pm one night a week?
Yes
No |
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7:00 am– 3:30 pm on a Saturday at least 3 times?
Yes
No |
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Any skills, hobbies, or previous experiences you would like to share: |
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Any physical limitations: Yes No
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| | If yes, please explain:
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Is it OK to take pictures of you for bulletin boards, newsletters, etc?Yes No
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**Hillview does not accept any person involved in theft, abuse, or drug cases.**
INTERNS WILL HAVE A CAREGIVERS BACKGROUND CHECK COMPLETED
By submitting this form, I understand that it is my responsibility to keep confidential any information I learn about the residents and/or their family, and that violating confidentiality is cause for immediate dismissal. |
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