CCSS Internship Inquiry/Application Form
Personal/Educational Information
Please provide your full name (as spelled on your school ID): *
Please provide the best email address to reach you: *
Please provide the best phone number to reach you: *
Please provide your address: *
Please provide your age, nationality, ethnicity, and date of birth: *
Please list all languages you are able to speak, read, and write: *
What is your major? What is your minor? *
Expected graduation date:
Level of study: *
How many credits are required for completion? How many credits have you earned?
Field Instructor Information
Please provide name and contact information for the person at your school who will be providing information about internship criteria and overseeing your internship performance: *
Areas of Interest
Which domestic violence program are you interested in? (Rate 1-5 in order of preference). Options: A. Emergency Shelter, B. Emergency Services (Hotline/ Rapid Re-Housing), C. Counseling Program, D. Transitional Housing Program, E. Court Advocacy Program, and F. Prevention and Education Program. 1 is most interested, 6 is least interested. *
Domestic Violence Training Background
Do you have a 40-Hour Domestic Violence Advocacy Certificate? *
Have you completed the 20-Hour domestic violence training via the Illinois Coalition Against Domestic Violence? *
Do you have a personal Illinois Coalition Against Domestic Violence account? *
Internship Specifics
Do you have a copy of (or access to) the internship requirements from your school? *
What are the start and end dates for the internship? *
How many internship hours are needed? *
Which days and hours are you available to work? *
Please provide time and date options for a CCSS representative to contact you. (Example: 4/30/2020 at 2P via phone): *
Emergency contact information: *
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This form was created inside of Crisis Center for South Suburbia.