Position Title:

Information and Crisis Services (HotLine)

How did you hear about us?

advertisement

agency fair

brochure

community of faith

employer

friend

instructor/professor

radio/TV

“You Are Needed” Column

other

1. General Information

(h)

(w)

Name:

Phone:

Street Address:

E-Mail:

City:

State:

Zip Code:

Birthday:

Place of Employment

2. Student Information

Name of High School/College/University:

Major(s):

Graduation Date:

Faculty Advisor:

Phone:

Department:

Internship hrs. required:

3. Availability   (Check all that apply)

Mon-Fri

a.m.

afternoon

after 5 p.m.

Sat-Sun

a.m.

afternoon

after 5 p.m.

Summer?

yes

no

4. References  Pleas list two references (instructor, employer, counselor, pastor) who would be good judges of your character.

1.  Name:

Relationship:

Street Address:

City:

State:

Zip Code:

2.  Name:

Relationship:

Street Address:

City:

State:

Zip Code:

5. Emergency Information

First Emergency Contact:

 Name:

Relationship:

Street Address:

City:

State:

Zip Code:

Phone (include area code)

(h)

(w)

Second Emergency Contact:

 Name:

Relationship:

Street Address:

City:

Zip Code:

State:

Phone (include area code)

(h)

(w)

Insurance Company:

Policy Number:

Physician:

Hospital Preference:

Medical Condition(s) we need to be aware of (allergies, etc...):