Internship Application Applicant InformationName* Email* Phone number*Internship start date* MM slash DD slash YYYY Internship end date* MM slash DD slash YYYY University/College* Expected Graduation Date* MM slash DD slash YYYY What degree are you pursuing? (beaacalaureate, MSW, MFT, PCC, etc)* Hours of fieldwork needed per week (ex: 20 hours, 3 days, etc)* Will this be your first internship?* Yes No Fieldwork days (Mon, Wed, Fri, etc)* Are you seeking a stipend for your internship?***Please note that this is site specific and not guaranteed Yes No Please indicate the supervision requirements of your program (ex: only MSWs or those two years past licensure, or with a PPSC). Please attach any relevant forms your school has provided, as we cannot guarantee supervisor credentials that are not requested in advance.* Applicant InterestsPlacement Setting(Check all that apply. Please note that not all of these settings may be available in your area.) Adoption and Permanency School-based Crisis Support/Diversion Mental Health Community-Based Residential Which populations are you interested in working with? (Rank your choices: 1=1st Choice)Infants and Preschool Age* Middle School Age* Transitional Aged Youth (16- 25)* Youth on Probation* Elementary School Age* High School Age* Family Work- focused* Youth in Foster Care* Geographic location: In which locations are you interested in working? Northern California Northern California Alameda County Butte County Nevada County Placer County San Joaquin County Shasta County Solano County Sonoma County Tehama County Yolo County Yuba-Sutter County Southern California Southern California Riverside County San Bernardino County Los Angeles County Do you have a car available? (Some sites are not accessible by public transport and we provide transportation for clients in many programs):* Yes I have a car, am insured and able to transport clients. Yes I have a car, am insured but not able to transport clients. No I do not have access to a car, but am willing to drive a vehicle if one is provided. No I do not have access to a car, and could not drive one if provided. How did you hear about Victor?Please expand on your personal and professional goals that you hope to achieve while interning or training at Victor:Additional comments:Thank you for your interest in fieldwork at Victor Please note that it may take up to ten business days to hear back from us regarding the status of your application. If you have any further questions please contact us at internships@victor.org Δ
