*1.First Name(Required.)

*2.Last Name

(Required.)

*3.Contact Information(Required.)

Address *

Address 2

City/Town *

State/Province *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code *

Country

Email Address *

Phone Number *

*4.Which race/ethnicity best describes you? (Please choose only one.) (Required.)

African American

Asian American

Asian/Indian Subcontinent

Hispanic/Latino

Mexican American/Chicano

Native American

Native Hawaiian/Pacific Islander

Puerto Rican

White/Caucasian

Multiple ethnicity / Other (please specify)

*5.Name of the 2 or 4 year college/university you are currently enrolled in(Required.)

*6.Anticipated Graduation Year(Required.)

*7.What is your major?(Required.)

*8.Location of High School you graduated from (only enter city/country if you are an international student)(Required.)

City/Town *

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

Country *

*9.Hometown zipcode (enter 00000 if you are an international student)(Required.)

*10.Internship Status(Required.)

Participated in summer 2021 internship or co-op

Currently (as of October 1, 2021) in a fall internship or co-op

*11.Was your internship paid? (Choose one)(Required.)

Paid

Unpaid

Underpaid (<$15/hr)

*12.Duration of internship(Required.)

Start Date

End Date

Total number of hours

*13.Internship Job Title(Required.)

*14.Share a summary of your internship responsibilities(Required.)

*15.Name and Address of Internship Employer(Required.)

Name of Supervisor *

Company *

Address *

Address 2

City/Town *

State/Province *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code *

Email Address of Supervisor *

Phone Number of Supervisor *

*16.Employer Website(Required.)

*17.Please share your future career aspirations in Tech (In 500 words or less)(Required.)

*18.Outside of your classes and your internship, how have you been involved in the Philadelphia Tech community? (In 500 words or less)(Required.)

*19.In what ways has Campus Philly helped you connect to an internship or job? (Please check all that apply)(Required.)

I attended a virtual job fair hosted by Campus Philly

I attended a virtual career event with a recruiter or employer, hosted by Campus Philly

I learned about an interesting employer through Campus Philly

I receive Campus Philly emails with job and internship info

I follow Campus Philly on social media

Other (please specify)

None of the above

20.Would you like to receive information about our partners in the Most Diverse Tech Hub initiative?

Coded by Kids - Tech and Innovation internships for college students

Venture for America - Fellowship opportunities for recent college grads

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