Internship Application

Applicant Information

Field of Study*

Zumbro Valley Health Center accepts interns for the following degrees. Please check all that apply:

Dual license as an LPCC/LICSW and LADC
Bachelor's in Social Work
Bachelor's Degree in pursuit of a license in Alcohol & Drug Counseling
Master's in Social Work
Master's in Counseling
Other

Please Specify Other Field of Study*

Are you currently an employee at Zumbro Valley Health Center?*

Yes
No

Date*

First Name*

Last Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

School Information

School Name*

Street Address City State ZIP Code

Major*

Minor*

Year in School*

Current GPA or Pass/Fail Status*

Expected Date of Graduation*

Advisor Name*

First Last

Attach your program objectives or requirements that are required for completion of internship*

Max. file size: 512 MB.

Other

Is there a specific population of interest you would like to work with?

Do you speak and understand any foreign languages?*

Yes
No

Please list all languages spoken fluently:*

Please list the duration of when you are looking to complete internship with start and end dates*

What is the total number of hours your internship requires?*

What are the days and times you are available?*

Do you have a driver's license and use of car?*

Yes
No
License Only

How did you hear about Zumbro Valley Health Center?*

Social Media
Internet Search
Referral
Career Fair
Other

Cover Letter (pdf)*

Drop files here or

Accepted file types: pdf, Max. file size: 512 MB.

Resume*

Max. file size: 512 MB.

References*

Max. file size: 512 MB.

HIPAA Privacy Policy*

I have read and agree to the HIPAA Privacy Statement.

Notice of Information/Privacy Practices

This "Notice of Information/Privacy Practices" is used to inform website visitors regarding our policies with the collection, use, and disclosure of Personal Information if anyone decided to use our Service.

If you choose to use our Service, then you agree to the collection and use of information with anyone except as described in this Privacy Policy.

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Changes to This Privacy Policy
We may update our Privacy Policy from time to time. Thus, we advise you to review this page periodically for any changes. We will notify you of any changes by posting the new Privacy Policy on this page. These changes are effective immediately after they are posted on this page.

Name

This field is for validation purposes and should be left unchanged.

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