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Internship Inquiry Form
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Personal Information
Name
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First Name
Last Name
Current Address
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required
Street
City
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required
State
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AK
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Primary Phone
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Secondary Phone
Email Address
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required
Program Information
College/University
*
required
Expected Graduation Date
*
required
Must contain a date in M/D/YYYY format
Clinical Supervisor
*
required
Phone Number
Internship/Practicum Preferences
Field of Interest
*
required
Speech-Language Pathology
Deaf Education
Early Childhood
Learning Disabilities
Occupational Therapy
Reading
Requested Semester
*
required
Fall
Spring
For summer requests, please complete the summer program inquiry form.
Availability
*
required
Full time
Part time
Previous Experience
Clinical Hours Completed
Graduate
*
required
Undergraduate
Total
*
required
Current Education
Institution
*
required
Dates
*
required
Degree
*
required
Major
*
required
Minor
GPA
*
required
Undergraduate Education
Institution
*
required
Dates
*
required
Degree
*
required
Major
*
required
Minor
GPA
*
required
Add additional education?
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required
Yes
No
Institution
*
required
Dates Attended
*
required
Degree
*
required
Major
*
required
Degree
*
required
Minor
GPA
*
required
Descriptions of previous internships
Please include placement, ages and disorders of clients, and length of placement.
Memberships in Professional Organizations/Honors
Areas in which you will need additional hours/experience
Give a brief autobiographical sketch
What unique skills do you bring to this internship?
Why do you want to be an intern at the Atlanta Speech School?
Are there any special circumstances we should know about when making your internship arrangements?
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