APPLICATION FOR INTERNSHIP

Suncoast Center, Inc. is an Equal Employment Opportunity Corporation (EEOC) which makes employment decisions without regard to race, color, sex, religion, national origin, age, handicap, disability, marital or veteran status, or sexual orientation. Suncoast Center also reasonable accommodates individuals with handicaps, disabilities and bona fide religious beliefs.

Suncoast Center, Inc. is a Drug-Free Workplace and abides by the Clean Air Act.
(Please print and completely answer all questions)

  Suncoast Center, Inc. Intern Application

 
Last Name

 
First Name

 
Middle Name or Initial

 
Address

 
Apartment Number or Unit

 
City

 
State

 
Zip Code

 
Phone

 
Are you at least 18 years old?

 
If not state your age for child labor law purposes only

 
Are there any days or hours you will not be able to paticipate?

 
If yes please explain

 
What is your anticipated start date for internship?
Use Date format "mm/dd/yyyy":

 
What is the duration of your internship?

 
Provide any dates that you will not be permitted to see clients due to a break in classes/semesters.

 
Can you within three days of employment submit documentation verifying that you are legally eligible to work in the United States?

 
Have you taken any illegal drugs in the last 30 days?

 
How did you learn about our organization?

 
Have you ever applied or worked here before?

 
If Yes provide dates

 
List any relatives or friends currently employed here

 
Who should be contacted in case of an emergency?

 
Full Address of Emergency Contact

 
Phone Number of Emergency Contact

 
Relationship of Emergency Contact

 
List any education work-related skills training or experience you believe are relevant to the internship
(8000 characters maximum)


 
Why did you decide to pursue a career in mental health?
(8000 characters maximum)


 
Why do you want to complete your internship at this organization?
(8000 characters maximum)


 
What would you like to gain or take-away for your internship?
(8000 characters maximum)


 
What populations are you most interested in working with?
(e.g. elderly, persons with a history of trauma, children, adolescents, persons with serious mental illnesses, families, etc.)
(8000 characters maximum)


 
Education

 
Military Branch of Service

 
Military Service Start Date
Use Date format "mm/dd/yyyy":

 
Military Service End Date
Use Date format "mm/dd/yyyy":

 
Military Rank at Discharge

 
Military Date of Discharge
Use Date format "mm/dd/yyyy":

 
Were you honorably discharged?

 
Describe any military skills training or experience you believe are relevant to an internship

 
Do you have a valid Florida Driver's License?

 
Have you had any moving violations in the last 5 years?

 
If yes please explain the moving violations

 
Have you had any DUI or DWI convictions?

 
If yes please explain the conviction(s)

 
Do you have a reliable form of transportation to work?

 
Have you ever been convicted of a felony or do you have any pending arrests/convictions?

 
If Yes explain and give dates

 
Referral Source

 
Referral Source Name

 
Referral Source Phone Number

Affirmative Action Survey - Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information in the next 3 items is voluntary:
 
Select Your Gender

 
Select Your Race or Ethnicity

 
Select one of the following if applicable

Required Signature and Submission:
 
Type Your Full Name Here and then submit:

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