* 1. Name (First Last)

* 2. Email

* 3. Cell Phone Number

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

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

* 6. What is your availability?

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

* 8. What is your preferred method of contact?

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

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

Date

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

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

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

* 14. What is the deadline for your hours?

Date / Time

* 15. What is the title of your course?

T