Student Internship Application CONTACT If you have any questions, please contact gmombrun@integrityhouse.org. Student Internship Application "*" indicates required fields Δ Step 1 of 5 20% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*School Email* School Name*Major*Internship Start Date* MM slash DD slash YYYY Internship End Date* MM slash DD slash YYYY Credentials Required by Intern Supervisor*Please list any and all credentials required by your on-site supervisor at Integrity House to meet your program's prerequisites. Please list NA if this is not a requirement of your program.Weekly Hours Required*Total Hours Required (Per Term)*School Field Office Contact Name* First Last School Field Office Contact Email* Availability*Please list the days and times you are available. For example, Mondays from 9am to 3pm, Wednesdays from 2pm to 5pm, etc.Experience*Describe any student organizations, job experiences, additional coursework (undergraduate and graduate), skills, degrees, certifications, or licenses that you have that will help you with this internship.Career Goals*Describe your career goals and how this internship will help you reach those goals. Be specific about the experiences you want to gain through this internship and why you believe this internship can provide such an experience.Current Academic Status*SophomoreJuniorSeniorGraduate: 1st YearGraduate: 2nd YearGraduate: 3rd YearOtherAre any of your relatives or friends employed by Integrity House?*YesNoName* First Last Site Preference*Students placement location will be determined by Integrity House's needs, but the organization will aim to accommodate location preference. Please list any of the following sites in order of preference: Newark, Secaucus, Morris Plains, Toms River, Kearny (Corrections). Add Remove Please upload your resume.* Drop files here or Select files Accepted file types: doc, pdf, Max. file size: 50 MB. Did you attend high school?*YesNoHigh School Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Degree*Did you attend a trade school?*YesNoTrade School Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Certificate*Did you attend an undergraduate university or college?*YesNoStatus* I am currently enrolled in a program. I have graduated from a program. University Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date* MM slash DD slash YYYY End Date*If you are still enrolled, what is your anticipated completion date? MM slash DD slash YYYY Degree*Did you attend graduate school?*YesNoProgram Status* I am currently enrolled in a program. I have completed a program. Graduate School Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date* MM slash DD slash YYYY End Date*If you are still enrolled, what is your anticipated completion date? MM slash DD slash YYYY Degree* Primary Emergency Contact Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Relationship*Secondary Emergency Contact Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Relationship* Fingerprinting* I acknowledge that I have read and understand the following.The agency agrees to pay for fingerprinting, unless the student intern cancels and/or reschedules the appointment, at which time the student intern will then be responsible for re-payment to the agency and for payment of the newly scheduled appointment. Additionally, the student intern agrees that if they decide to withdraw their application after completing the fingerprinting process that they will provide the agency with re-payment of the cost of fingerprinting.Disclosure for the Provision of Supervised Treatment Services* I acknowledge that I have read and understanding the following.All student interns are required to complete the Disclosure for the Provision of Supervised Treatment Services with each and every client with whom they will work at the beginning of the assignment. This must be documented in the client's electronic health record. Such disclosure will inform the client that treatment services provided to them are by an intern, under the clinical supervision of a New Jersey Licensed Professional, per N.J.A.C. 13:34-6.2(c). Student interns are prohibited from recording any clinical activity, without prior written approval from Integrity House.Agreement* I acknowledge that I have read and understand the following.I hereby acknowledge that I have received and reviewed Integrity House's policies related to student interns, the code of ethics, and confidentiality procedures and requirements. I understand that I am obligated to abide by these and all Integrity House policies, if I am to begin and continue my service at Integrity House. I am aware that any violation of Integrity House policies on my part will result in the immediate termination of my service and professional relationship with Integrity House. I understand that any misstatement, omission or misleading information given in my application, resume or interview in connection with other Integrity House records may result in the rejection of my application, the withdrawal of any internship or volunteer offer, or my dismissal. I understand that my internship or volunteer offer is contingent upon my satisfactorily completing the following: (a) proof of physical exam within the last 30 days, (b) proof of MMR, (c) proof of two-step (PPD testing conducted twice within one month) PPD within the last year, (d) negative drug screen results, and (e) background check. I understand that all placements are on-site.
