PATCH Program Internship Application
Applicant Information
Name *
Street Address *
City *
Zip Code *
Phone Number *
Email Address *
Date of Birth *
Race/Ethnicity (Optional)
Gender Identity (Optional)
Emergency Contact Name *
Emergency Contact Phone Number *
Internship Details
I'm interested in helping PATCH with... *
How long are you interested in interning with PATCH? *
When would you be available to start?
How many hours/week would you be able to commit to this internship?
What would be your ideal schedule? Please include preferred days and times.
Application Questions
How did you learn about PATCH and our internship opportunities? *
Why are you interested in interning with PATCH? *
How do you think interning for PATCH would help you with your education or career goals? *
What skills, knowledge, experience, or passion do you have that you think will make you a successful intern? *
In your opinion, why is it important to invest in adolescent health? *
Is there anything else you'd like us to know about you? *
Please provide a copy of your resume. If you have any challenges with the file upload, please e-mail us at
Electronic Signature & Confirmation of Application
Final Confirmation
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