Internship Form

Name*
Prefix First Last
Personal Pronouns (ex: she/her, they/them, he/his)
Local Address*
Street Address Address Line 2 City State ZIP Code
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
Languages Spoken*
Are you a veteran?*
- Yes
- No
What is your COVID-19 vaccination status?*
- I am fully vaccinated.
- I am not fully vaccinated, but will be prior to the start of this internship.
- I am not vaccinated.
At this time, to protect our clients, staff and interns, all interns must be fully vaccinated against COVID-19 and able to provide documentation of their vaccination status.
What days will you be available?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
School*
Major*
Date available to start*
MM slash DD slash YYYY
Date internship hours should be complete*
MM slash DD slash YYYY
Total hours to complete*
First choice for placement*
- Adult Day Health
- Center for Active Living
- Volunteer Relations
- Meals On Wheels
- Grandparents Raising Grandchildren
- Any
Second choice for placement*
- Adult Day Health
- Center for Active Living
- Volunteer Relations
- Meals On Wheels
- Grandparents Raising Grandchildren
- Any
Hidden
Second choice for placement*
- Adult Day Health
- Center for Active Living
- Volunteer Relations
- Any
Please comment on your interest in interning with ACCA*
Field supervisor
Enter the name and contact information for the faculty member overseeing your internship or field placement.
Name*
Prefix First Last
Email*
Phone*
Reference
Name*
First Last
Email*
Phone*
Emergency Contact
Name*
First Last
Email
Phone*
Alternate Phone
Emergency Information
Local Hospital Preference*
Preferred Physician*
Medical Conditions*
Allergies*
Driving Info
Will you be driving your car or an agency vehicle during your internship?*
- Yes
- No
Drivers License #
State
Expiration Date
MM slash DD slash YYYY
I understand that if I use my personal automobile as an ACCA intern I must arrange to keep liability insurance equal to or greater than that required by the state of Georgia.*
Statement of Conduct: I have never been shown by credible evidence to have abused, neglected, or exploited any person as written in the Volunteer Handbook.*
Statement of Confidentiality: I agree that information I receive about ACCA clients or members in the course of my internship will be held in confidence by me.*
Photo Release: I give my permission to have photographs/videos taken of me at the ACCA, and/or at any program or activity sponsored by the agency. I understand and approve the use of these photographs/videos for the purposes of showing services given by ACCA. I understand and approve the use of these photographs/videos to publish in print and/or electronically. This could include publications such as newspapers, press releases, internet web pages, social media outlets, and/or newsletters. The ACCA may publish materials, use my name, photograph/video, and/or make reference to me in any manner that the agency deems appropriate in order to promote and publicize services.*

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Field supervisor

Reference

Emergency Contact

Emergency Information

Driving Info