Name:  _______________________________________
 
Email:  _______________________

Phone (the best number to reach you):  __________________________

Permanent Address: ____________________________________________________

College/University:  _____________________________________________________

School Address: _______________________________________________________

Send correspondence to: (check one)
     Permanent Address  _____   School Address  _____

Major(s):  ____________________________________

Minor(s):  ____________________________

GPA:  _______          Desired Number of Credits:  _________

Number of Total Hours:  _________

The internship will be taken for:  (check one)
                                                                 Credit  ________     Non-Credit ________

Proposed Internship Dates:  Starting:  ______________________
 
Ending ______________________

Internship Advisor/Phone Number:  __________________________________________

Days Interested in Working at CCHS:     M      T      W      Th      F

Desired Hours at CCHS:  ____________________________

How Did You Learn About CCHS?  ______________________________________

Additional Information:

Emergency Contact/Phone:  _________________________________________

Medical Information: ____________________________________________________

Physical Limitations:  ____________________________________________________

Please include your resume, an official copy of your academic transcript, and one letter of recommendation or endorsement.

On a separate sheet of paper, briefly describe any education or work experiences incurred that may relate to your
area(s) of interest at CCHS.  Additionally, what do you hope to achieve from interning at CCHS?

NOTE:  An interview is required and will include a discussion of possible projects and guidance to areas of interest.

Send completed application and related materials to:

Executive Director
CCHS Internship Program
21 N Pitt St
Carlisle, PA 17013

Signature:  ____________________________________              Date:  ________________
 
 

For office use only:

Application and
Related Materials Received: (Date)____________
Interview Conducted:  _____________
        Orientation:  _____________

Rev. 5-Ap-07