AVA Community Agency Internship Application (Agency Form) Agency & Contact Information Question Title * 1. Name of Community Agency Question Title * 2. Who is completing this form? Name (first, last) Preferred pronouns Role (e.g. community agency leader, academic partner, scholar, AVA Lead on behalf of a community agency) Email address Question Title * 3. Who is the person at the agency that will be leading the internshipNote: This person will be referred to the Agency Internship Leader. Question Title * 4. Agency internship leader's preferred pronouns Question Title * 5. Agency internship leader's email address Question Title * 6. Is there someone co-leading this internship (e.g. a colleague at your agency; academic partner)? Yes No Question Title * 7. Please provide the contact information for the person co-leading the internship Name Organization/Agency Email Address Question Title * 8. Has the internship leader participated in the AVA Triadic Mentorship Program (TMP)? The internship leader or co-leader is currently participating in the AVA TMP. The agency internship leader or co-leader has participated in the AVA TMP in the past. The agency internship leader or co-leader have never participated in the AVA TMP. Other (please specify) Question Title * 9. If the agency internship leader or co-leader is currently participating in the AVA Triadic Mentorship Program, please specify the academic mentor’s name below. Question Title * 10. In point form, what skills or expertise does the Agency Internship Leader and Co-Leader (if applicable) possess, that will contribute to leading an intern in the AVA Community Internship Program (maximum 250 words). Question Title * 11. Agency internship leaders and co-leaders (if applicable) must read the AVA Community Agency Internship Overview document. This is required to submit the application. The agency internship leader and co-leader (if applicable) have read the document and do not have any questions. The agency internship leader and co-leader (if applicable) have read the document, but have questions and would like to be contacted by an AVA team member to discuss them. Please specify who to contact below. Contact info Next