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 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*
Which programs are you interested in being placed with?*
- Select All
- Adult Day Health
- Care Coordination
- Center for Active Living
- Dementia Resource Center
- Grandparents Raising Grandchildren
- Meals on Wheels
Check all that you are interested.
First choice for placement*
- Adult Day Health
- Care Coordination
- Center for Active Living
- Dementia Resource Center
- Grandparents Raising Grandchildren
- Meals on Wheels
Depending on capacity, we may be able to meet your first choice for placement, otherwise we will work with you to find the best fit.
Please comment on your interest in interning with ACCA*
Resume
Max. file size: 50 MB.

Please upload a copy of your resume here
Cover Letter
Max. file size: 50 MB.

If you have a cover letter, please upload it here. A cover letter is not required however.
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
Relationship to Your Emergency Contact*
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