Internship Application Form

Personal Details

Name / Phone number(s)
Have you ever used another name?
[if yes, give details] / Home address
Email address / Nationality
Sex / Male
Female / Languages spoken
Emergency contact name and relationship to you / Emergency contact phone number
Which role are you applying for? / Are you willing to commit to 6 months part time interning with us?
How/where did you hear about this internship role? / When are you available to start?

Educational and vocational qualifications

Institution / Qualifications gained / Dates from and to / Course details

Employment

Employer name and address / Position held and main duties / Dates from and to / Reason for leaving
Please provide reasons for any gaps in between employment and/or full time education

Voluntary experience

Organisation name and address / Volunteer role details / Dates from and to / Reason for leaving
Please give details of any other relevant experience
Personal Statement
(Please keep your personal statement to no more than 2 pages)
Why are you interested in interning with Young Roots?
What skills and experience will you bring to this role? (Please refer to the person specification and the job description)
What do you hope to gain from an internship with Young Roots?

Referee Details

Please give details of two academic or professional referees who must have known you for at least one year. We cannot accept references from personal friends or family members.
Referee name and relationship to you / Referee name and relationship to you
Referee email address / Referee email address
Referee address / Referee address
Referee phone number / Referee phone number

Disclosure of Criminal Convictions – Rehabilitation of Offenders Act 1974

The appointment of any intern who may have contact with or access to children or
vulnerable adults will be subject to the receipt of a satisfactory disclosure from the Disclosure & Barring Service. The presence of a criminal record will not necessarily prevent involvement with Young Roots. Please make the following declaration by marking the appropriate box.
I have nothing to declare
I have information to declare
[please give details]
I declare that the information given in this application is correct
Signed:
Date:

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