Internship Application .us



Internship ApplicationOregon Vocational Rehabilitation welcomes student interns from Rehabilitation Counseling and related training programs. This document will give you the opportunity to apply for an internship. Please complete all sections of this application including attaching a current resume, cover letter and unofficial school transcript. A copy of this application will be kept with the VR Internship Coordinator as well as being shared with the Branch Managers and potential Site Supervisors at the VR Offices you have indicated on this application. All students placed in VR offices must pass a background check before they can begin onsite. Having a criminal background will not necessarily prevent your ability to serve as an intern with VR.Student contact informationName: FORMTEXT ?????Pronoun(s): FORMTEXT ?????Address: FORMTEXT ?????Email: FORMTEXT ?????Primary phone: FORMTEXT ?????Secondary phone: FORMTEXT ?????I am applying for an internship experience as: (Check all that apply) FORMCHECKBOX VR Counselor Practicum FORMCHECKBOX VR Counselor Intern FORMCHECKBOX Counselor Assistant/HSA2 FORMCHECKBOX VR Program AdministrationAcademic informationCollege or University: FORMTEXT ?????Program of study: FORMTEXT ?????City and State: FORMTEXT ?????Student status: FORMCHECKBOX GraduateClinical Coordinator: FORMTEXT ????? FORMCHECKBOX UndergraduatePhone: FORMTEXT ?????Email: FORMTEXT ?????Length of program: FORMTEXT ?????Current year in program: FORMTEXT ?????Anticipated graduation (month/year): FORMTEXT ?????My school schedule is based on: FORMCHECKBOX Quarters FORMCHECKBOX SemestersPracticum information (Please skip this section if you are not completing an practicum)According to my program’s curriculum, I am expected to complete FORMTEXT ????? hours per week on my practicum site.Term(s): FORMCHECKBOX Fall FORMCHECKBOX Winter FORMCHECKBOX Spring FORMCHECKBOX SummerDays and times availablefor practicum: FORMCHECKBOX MondayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX TuesdayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX WednesdayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX ThursdayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX FridayFrom: FORMTEXT ?????To: FORMTEXT ?????Students will work with their site supervisor to determine their actual practicum schedule based on all parties’ availability.Internship information (Please skip this section if you are not completing an internship)According to my program’s curriculum, I am expected to complete FORMTEXT ????? hours per week on my internship site.Term(s): FORMCHECKBOX Fall FORMCHECKBOX Winter FORMCHECKBOX Spring FORMCHECKBOX SummerDays and times availablefor internship: FORMCHECKBOX MondayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX TuesdayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX WednesdayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX ThursdayFrom: FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX FridayFrom: FORMTEXT ?????To: FORMTEXT ?????Students will work with their site supervisor to determine their actual internship schedule based on all parties’ availability.Language proficiency informationDo you have proficiency in languages other than English? FORMCHECKBOX Yes FORMCHECKBOX NoPlease rate your fluency as Beginning, Intermediate or Advanced.American Sign Language:ExpressiveEnglish-ASL FORMTEXT ?????ReceptiveASL-English FORMTEXT ?????Spoken languages:SpeakReadWriteLanguage: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Language: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Culture and diversity informationThe following questions are voluntary but will help us in our efforts to ensure our internship program is equitable and diverse in its recruitment and placement activities.Choosing not to answer them WILL NOT affect your chances of being placed with Oregon VR for your internship.How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry? FORMTEXT ?????Which of the following describes your racial or ethnic identity? (Please check ALL that apply)Hispanic and Latino/a/x FORMCHECKBOX Central American FORMCHECKBOX Mexican FORMCHECKBOX South American FORMCHECKBOX Other Hispanic/Latino/a/xNative Hawaiian and Pacific Islander FORMCHECKBOX Chamorro FORMCHECKBOX Marshallese FORMCHECKBOX Communities of theMicronesian Region FORMCHECKBOX Native Hawaiian FORMCHECKBOX Samoan FORMCHECKBOX Other Pacific IslanderWhite FORMCHECKBOX Eastern European FORMCHECKBOX Slavic FORMCHECKBOX Western European FORMCHECKBOX Other WhiteAmerican Indian and Alaska Native FORMCHECKBOX American Indian FORMCHECKBOX Alaska Native FORMCHECKBOX Canadian Inuit, Metis, orFirst Nation FORMCHECKBOX Indigenous Mexican,Central American, orSouth AmericanBlack and African American FORMCHECKBOX African American FORMCHECKBOX Afro-Caribbean FORMCHECKBOX Ethiopian FORMCHECKBOX Somali FORMCHECKBOX Other African (Black) FORMCHECKBOX Other BlackMiddle Eastern and North African FORMCHECKBOX Middle Eastern FORMCHECKBOX North AfricanAsian FORMCHECKBOX Asian FORMCHECKBOX Indian FORMCHECKBOX Cambodian FORMCHECKBOX Chinese FORMCHECKBOX Communities ofMyanmar FORMCHECKBOX Filipino/a FORMCHECKBOX Hmong FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Laotian FORMCHECKBOX South Asian FORMCHECKBOX Vietnamese FORMCHECKBOX Other AsianOther categories FORMCHECKBOX Other (please list) FORMTEXT ????? FORMCHECKBOX Don’t know FORMCHECKBOX Don’t want to answerIf you checked more than one category above, is there one you think of as your primary racial or ethnic identity? FORMCHECKBOX Yes. My primary racial or ethnic identity is FORMTEXT ????? FORMCHECKBOX No. I identify as Biracial or Multiracial. FORMCHECKBOX I don’t want to answer this question.Do you have a physical, cognitive or emotional disability? FORMCHECKBOX Yes, I do have a disability.Are you CURRENTLY a client of Oregon VR? FORMCHECKBOX Yes FORMCHECKBOX NoIf so, which office or VR Counselor are you working with? FORMTEXT ?????Will you need accommodations other than those provided by your university to successfully complete your internship experience with us? FORMCHECKBOX Yes, I will. FORMCHECKBOX No, I will not. FORMCHECKBOX Unsure FORMCHECKBOX No, I do not have a disability. FORMCHECKBOX I don’t want to answer this munity service/volunteer activitiesPlease list any experience working directly with people with disabilities and other diverse lived experiences. Include any previous practicum/internship experiences. FORMTEXT ?????Internship goalsWhat is your understanding of what Vocational Rehabilitation is and does? FORMTEXT ?????Why are seeking an internship with Oregon VR? What do you hope to gain from the experience? FORMTEXT ?????What are you looking for in a site supervisor and office? FORMTEXT ?????What skills, abilities and attitude will you bring to a clinical site if accepted? FORMTEXT ?????Describe the work you hope to do post-graduation. Please include agency/program, types of disability, clients’ lived experiences, area of the state or country, and any community partners you would like to work with. Please provide 3-4 sentences. FORMTEXT ?????Which location(s) are you interested in? You can find our locations on our webpage. FORMTEXT ?????Why do these locations interest you? FORMTEXT ?????Professional references (At least one of these individuals must have directly supervised you at some time in your work or school history)Name FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Email address FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone/VP FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Business & position FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Length of relationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ????? Applicant signature DatePlease send this completed application, a current resume, a cover letter and unofficial (web based) school transcript to VR.Internship@odhsoha..This form is available in alternate formats if needed. Please contact the Internship Coordinator in the VR Administration Unit in Salem to make that request. You may email VR.Internship@odhsoha. or call (503) 945-5880 or 1-877-277-0513. All relay calls are accepted. ................
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