Community Service Council

Practicum/Internship Application

Internship Program

Internship Application

Initial Information
NAME / DATE
ADDRESS / CITY/STATE/ZIP
PHONE # / CELL/OTHER #
EMAIL / OVER AGE 18
YES☒ NO☒
Education/Practicum Information
COLLEGE/UNIVERSITY / DEGREE LEVEL/PROGRAM.CHOOSE ONEDOCTORALASSOCIATESBACHELORSMASTERSUNION/CAREERCONNECTOTHER
MAJOR / ANTICIPATED GRADUATION DATE
INTERNSHIP COORD NAME & TITLE / TITLE.
PHONE # / EMAIL.
COLLEGE/PROGRAM WEBSITE
Click for PRIMARY INTEREST AREA JOB POSTING TITLE
TOTAL HRS REQ FOR INTERNSHIP
ANTICIPATED START DATE ANTICIPATED COMPLETION DATE
APPROX # HOURS/WEEK.
REQUIRED GROUP OR INDIVIDUAL SUPERVISION HOURS PER WEEK

Experience/Training/Skills

List Employment, Military, Volunteer, or other EXPERIENCE relevant to your field of study/social services.
Indicate any Professional License/Certifications/Specialized Military or Other Training
Indicate any additional languages fluently spoken or written
Describe additional specialized SKILLS

Professional References

NAME / POSITION
/TITLE / PHONE/EMAIL / #
Years Known / RELATIONSHIP

Emergency Contact Information

NAME / PHONE # / RELATIONSHIP /

Applicant Certification:*This must be completed in order to consider your application

I HEREBY ATTEST that all statements made in this application are true and correct to the best of my knowledge. I understand and agree that any deception, fraud, or false or misleading statements of material facts in this application or in the application process may result in my release from consideration.

☐YES, I attest☐NO, I do not attest

Please type your name here as a digital signature:

Voluntary Applicant Affirmative Action Program Self-Identification

Community Service Council values diversity and encourages women and all minorities to apply.For this reason, we ask applicants to voluntarily indicate gender/race/ethnicity below. As a government contractor and in order to comply with regulations for equal opportunity employment and affirmative action (EEO/AA), CSC is required to track gender/race/ethnicity and position of applicants.Submission of this information is on a voluntary basis, and your refusal does not affect your chances of employment, or subject you to adverse treatment. Responses remain confidential and are used only for Affirmative Action Program reporting requirements of the government. This information is maintained separately from your application. Data is aggregated and does not identify specific individuals.

Gender:

☐Male☐Female ☐Transgender ☐Other ☐Choose not to answer

Race and Ethnicity:

☐Hispanic or Latino-a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race

☐White/Caucasian (Not Hispanic or Latino)

☐Black/African American

☐Native Hawaiian or Pacific Islander

☐Asian

☐American Indian or Alaskan Native

☐Two or more races-all persons who identify with more than one of these races.

☐Choose not to answer

Thank you for your interest in CSC!

Submit the completed Internship Applicationwith Resume:

Email to:

or

Please indicate in the subject line“Internship Application”

-OR-

Mail:

Attn: Internship Program

Community Service Council

16 East 16th Street, Ste 202

Tulsa, OK 74119

918- 585-5551 (Main)

Please contact Jennifer Freeman, LCSW, LADC for additional questions 918 699-4291

CSC, HR, Internship Application, Revised 01/08/2018