Cleveland Clinic Office of Civic Education Initiatives

Internship Application – ALL Programs


THIS IS A SECURE PAGE

* Required Fields
Student Last Name*
Student First Name*
SS#* --
Birthdate*
mm/dd/yyyy
(please use this format – do not use dashes)
Gender*
Religion
Ethnicity

Are you legally authorized to work
in the United States?*
   
Student Address*
City*
State*
Zip*
County*
Student Home Phone Number*
(If none please enter the number 0 in all boxes)
--
Student Cell Phone Number*
(If none please enter the number 0 in all boxes)
--
Student Email Address*(Enter an email you check frequently. DO NOT use a school-based email. If you do not have a personal email, please create a professional one NOW. This email will be used for ALL future program correspondence.)
Careers interested in (indicate up to three choices)*


Have you applied to one of our
Internship Programs before?*
(Check most recent year that applies)  
     
Which internship program did you apply to?*
(Check most recent program applied to)












If you applied and were accepted, did you successfully graduate from the Internship Program?*
(Check most recent year that applies)
        
Are you applying to be a Peer Mentor?    
Current School Name*
Current School Principal Last Name*
Current School Principal First Name*
School Address*
School City*
School State*
School Zip*
School District* (Please verify with your school office if you are unsure.)
School County*
Cumulative GPA*
Please indicate the Summer Internship Program you are applying to:* STUDENTS MAY ONLY SELECT ONE PROGRAM TO APPLY TO.
Current/Last Year Teacher Last Name*
Current/Last Year Teacher First Name*
Current/Last Year Teacher Email*
Current/Last Year Guidance Counselor First Name*
Current/Last Year Guidance Counselor Last Name*
Current/Last Year Guidance Counselor E-Mail*
Have you successfully completed any AP classes? *  
Have you successfully participated
in any PSEOP classes?*
 
Level of Computer Literacy*
My Time Management Skills are*
College/University of choice* (Please list only one. If you are currently attending college FULL TIME please list that college)
Extracurricular Activities at school*
Work Experience*
Volunteer Experience*
Parent/Guardian First Name*
Parent/Guardian Last Name*
Address*
City*
State*
Zip*
HomePhone Number*
(If none please enter the number 0 in all boxes)
--
CellPhone Number*
(If none please enter the number 0 in all boxes)
--
Personal E-mail*
Place of Employment*
WorkPhone Number*
(If none please enter the number 0 in all boxes)
--
Additional Emergency Contact First Name*
Additional Emergency Contact Last Name*
Place of Employment*
Emergency contact daytime Phone Number*
(If none please enter the number 0 in all boxes)
--
This is a*           
They are*
I would prefer a placement at (Location) *
(FINAL PLACEMENT LOCATION IS NOT GUARANTEED AND IS AT THE DISCRETION OF THE
SELECTION COMMITTEE)

I prefer a placement at (type) *

(FINAL PLACEMENT TYPE IS NOT GUARANTEED AND IS AT THE DISCRETION OF THE SELECTION
COMMITTEE)

Student Essay* (All essay questions MUST be answered to complete your application.)
Please answer the following statements to the best of your ability. Take time to think about and formulate your answers. Make sure your answers are concise but thorough.There is a 250 word limit for each answer

1. I am interested in being selected as an Internship Program participant because:

2. I possess the following science and/or research skills and experience that would help me in my work as an Internship Program participant:

3. I possess the following academic skills that would help me in my work as an Internship Program participant:

4. I possess the following personal skills that would help me in my work as a Internship Program participant:

5. I hope to increase my skills in the following areas:

6. I have experience using the following computer software:

7. If I had to choose a career today, it would be (and state why):

8. I am interested in returning to the Greater Cleveland community as a health care provider. Please answer yes or no and state why.

By clicking on the "Submit" button, I certify that the information contained in this form is accurate and complete. In addition, I understand and agree that falsification of information either by me or by others on my behalf will make me ineligible for consideration and/or will result in termination from the program. Further, I understand that clicking on the "Submit" button is equivalent to signing the application paperwork using my electronic signature, and I agree that these documents are legally binding according to the provisions given in the Electronic Signatures in Global and National Commerce Act (also known as E-Sign).


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