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* 1. Name (First Last)

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* 2. Email

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* 3. Cell Phone Number

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* 4. Are you willing and able to receive text messages?

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* 5. Which school are you completing your internship with?

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* 6. What is your availability?

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* 7. Are you able to meet at last once a month, in person or via teleconference?

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* 8. What is your preferred method of contact?

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* 9. What are you hoping to do with UCASA? Ex: Policy development, administrative work, outreach, etc.

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* 10. When are you hoping to begin your internship?

Date

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* 11. Is there anything you would like us to know?

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* 12. Is this for a course or strictly on a volunteer basis?

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* 13. If yes, how many hours are you required to intern for?

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* 14. What is the deadline for your hours?

Date / Time

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* 15. What is the title of your course?

T