Albert Einstein High School
ALBERT EINSTEIN HIGH SCHOOL
11135 Newport Mill Road, Kensington, MD 20895
Telephone: 301-929-2200 Fax: 301-962-1016
Principal: James G. Fernandez
Assistant Principals: Nate Collins, Micah Wiggins and Assistant School Administrator, Kisheena Wanzer
ACADEMIC INTERNSHIP PROGRAM APPLICATION FOR 2014-2015
Name______SS#______Grade______
(Last) (First) (Middle)
Address______
(Street) (Apt. No) (City) (State) (Zip)
______
(Home phone) (e-mail address)
If not a U.S. citizen, do you have a green card? YES NO Date of Birth: ______
Of what country are you a citizen?______
Full Name of Parent or Guardian______
(Last) (First)
Address: ______ (Street) (Apt. No) (City) (State) (Zip)
(Work phone) ______(Parent E-mail address) ______
Emergency Contact______Emergency Phone No. ______
High School: ______Current GPA:______
Counselor: ______Signature: ______
(please print)
If you are selected to be an intern, you must be able to provide your own transportation to your internship site. Does this pose a problem? Why? ______
______
Circle your choice: SINGLE PERIOD DOUBLE PERIOD TRIPLE PERIOD
All internships are two semesters unless prior permission is granted. (Most professionals do not want to train an intern for only one semester)
Have you had salaried work after school or during the summer? ______
Are your currently employed? ______
Employer:______Phone #:______
Name of Supervisor ______
Employer Address ______
Describe your job duties ______
PreviousEmployer:______Phone #:______
Name of Supervisor ______
Employer Address ______
Describe your job duties ______
Why did you leave this job? ______
Evaluate your academic performance (circle one): Excellent Good Fair Poor
Current GPA: ______
Comments: ______
______
Do you have any after-school obligations (for example, family obligations, sports, music lessons). If so, please list days and hours of the week when these occur.
______
______
Evaluate your school attendance: (circle one) Excellent Good Fair Poor
Number of days absent previous semester______
Do you have any health problems that may affect your attendance? Describe below. ______
What type of career would you like to learn about? ______
Where would you like to work? ______
SIGNATURE OF APPLICANT______Date______