Application for Educational Hours & Internships

Application for Educational Hours & Internships

Important!

After filling out the application below, please do not forget to submit the required documents in a separate email to Lisa Adams, ladams@sdcmh.org.

Required Paperwork Clinical Student Non-Clinical Student
University Required Paperwork X  
Background Check X  
Business Assocation Agreement (BAA) Signed by School (upon request) X X
Confidentiality Agreement X X
Resume/CVE X  
Certifications and Licenses X X
Proof of Liability Insurance X  
TB Skin Test (within last 12 months) X  
Competency Checklist from School X  

 

Required fields are marked with a

This application cannot be partially completed and saved. Please have all work history and other information accessible before entering data. Once the application is complete, be certain to read the "Waiver" section at the bottom of the form.
If in agreement with the terms of the waiver, select "I accept." Then select "Submit" at the bottom of the form.
APPLICANT INFORMATION
Last Name
First Name
M.I.
Maiden Name
Address
City
State
ZIP
Phone
Email
Are you a citizen of the United States?

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever been convicted of a felony?

Yes

No

If yes, explain
Area of interest
Preferred department or provider
Start date
Number of hours
SCHOOL OR UNIVERSITY
Name of School
Address
Instructor/Teacher Phone
Instructor/Teacher Email
PROFESSIONAL LICENSES, CERTIFICATIONS & SKILLS
Currently Licensed

Yes

Type
No.
State
Currently Licensed

Yes

Type
No.
State
License or registration ever suspended, revoked or on probation?
Special skills

Characters remaining:
WAIVER AND RELEASE
Click here to read the Waiver and Release.
After you have read the Waiver and Release, check one of the following buttons:

I accept the above written Waiver and Release

I do not accept the above written Waiver and Release

REQUIRED PAPERWORK

I will submit the required paperwork to ladams@sdcmh.org

SPAM Validation

Please type the text below