The Bridge to Hope Internship Application

Contact Information

Name: / Today’s Date: / DOB:
Mailing Address:
Home Ph #: / Cell Ph #:
Email:

School Information

School Name:
Field / Intern Coordinator Name: / Phone #:
Coordinator’s Email:
Degree Level, Program & Major/Focus:
# Internship hours to be completed with The Bridge to Hope:
Anticipated Internship
Start Date: / End Date: / Graduation Date:
# Internships required by your program: / Which Internship is this for you?
Does your program require any credentials of your supervisor?
Any other specific requirements of your program or supervisor?
What is your timeframe for securing an internship? (ie What is your school’s deadline?)
  1. Describe any previous social service experience. Include the name of the organization, how long you served and your duties/responsibilities.
  1. How did you find out about the Bridge to Hope? And what are your reasons for wanting to complete an internship with us?
  1. What would you like to gain from an internship experience?
  1. What, if any, domestic violence/sexual assault education experience do you have?
  1. What are your post-internship plans?
  1. Please list any special interests/skills/languages

Weekly Schedule

  1. Will you also be employed during the internship?
/
  1. If Yes, # hours per week?

  1. Do you have your own transportation? (If no, please describe your plans on how to get to our locations.)

Availability

Please list which hours each week you will be available to be on-site Monday-Friday, 8am-10pm:

Monday
Tuesday
Wednesday / Assist with Sexual Assault Survivor’s
Support Group 6-7pm Yes / No
Thursday / Assist with Domestic Violence Survivor’s
Support Group 6-7pm Yes / No
Friday
Saturday
Sunday

Weekend hours vary, depending on scheduled activities/fundraisers or additional help needed.

  1. What is your preferred number of Internship hours per week?

History and References

Have you ever been convicted of: (circle one)

Sexual AssaultYES NO

Indecent ExposureYES NO

Lewd & Lascivious BehaviorYES NO

Any Crime Involving Non-Consensual Sexual Contact/ConductYES NO

Child AbuseYES NO

Sexual Exploitation of ChildrenYES NO

Child AbductionYES NO

Child NeglectYES NO

Contributing To The Delinquency Of A ChildYES NO

Enticing A Child For Immoral PurposesYES NO

Exposing A Minor To Pornography YES NO

Exposing A Minor To Other Harmful MaterialsYES NO

Any Crime Involving Children As Victims Or Participants YES NO

Have You Ever Been Arrested/Convicted of Assault/Battery/Disorderly Conduct? YES NO

If you answered YES to any of these, please explain.

Charge
Conviction
Against Whom
What State
Date

Please list three (3) references (no family members):

Name
Relationship
Address
Phone
Name
Relationship
Address
Phone
Name
Relationship
Address
Phone