Internship Application Applicant InformationName* Email* Student Address* 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? (baccalaureate, 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. Please attach any relevant forms your school has provided, as we cannot guarantee supervisor credentials that are not requested in advance.LMFTLCSWLPCCPPSCOtherSupervision Requirement (other) Please upload your resume Drop files here or Select files Max. file size: 8 MB, Max. files: 1. Upload relevant school forms Drop files here or Select files Max. file size: 8 MB. Please provide the name of your contact/liaison at your school:Name Email PhoneApplicant 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 Chico Fairfield Grass Valley Manteca Red Bluff Redding Santa Rosa Stockton Truckee West Sacramento Southern California Southern California Barstow Hemet Lake Elsinore Perris Pomona San Bernardino Victorville (Campus) Victorville (Desert Mountain Region) West San Bernardino 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 click on the site name above that you are applying to for direct contact information. Δ
