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* 1. Student Demographic/Contact Information

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* 2. Current College/University Attending

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* 3. What is your educational program?
(Please specify the name of your program)

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* 4. What year are you in your educational program?

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* 5. What is your degree level?

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* 6. Are you interested in a clinical or non-clinical (administrative) internship?

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* 7. Please provide the name and contact information of your school's internship program coordinator:

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* 8. What is your enrollment status at the time of this application?

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* 9. How many hours per week are you available to work on an internship assignment?

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* 10. What system of care are you most interested in working with?

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* 11. Please enter your preferred internship assignment start date:

Date

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* 12. Upload Supporting Documents (Optional)
Please upload any relevant documents such as a resume, cover letter, or letters of recommendation.

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