Application for Recreational Therapy Internship Read more about the Recreational Therapy Internship Applicant Full Name:* Applicant Email Address* Home Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mobile Phone Number:*Social Security Number:* Driver's License (State/Number):* Who referred you to our company?* Are you at least 18 years old?* Yes No How will you get to work?*Are you willing to work any shift, including nights and weekends?* Yes No If no, please state any limitations:*If you are offered employment, when would you be available to begin work?* If hired, are you able to submit proof that you are legally eligible for employment in the United States?* Yes No Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?* Yes No What reasonable accommodation, if any, would you request?*Have you ever been convicted of a felony or misdemeanor?* Yes No THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.Conviction:* Date of conviction:* MM slash DD slash YYYY City of Conviction:* State of Conviction:* List current or most recent employer:* List all jobs (including self-employment and military service) which you have held, beginning with the most recent.Supervisor's name:* Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Job duties:*Reason for Leaving:*Dates of Employment (Month/Year):* List previous employer:* Supervisor's name:* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Job duties:*Reason for Leaving:*Dates of Employment (Month/Year):* Have you graduated?* Yes No Degree received: Date of graduation:* Are you a member of the American Therapeutic Recreation Association (ATRA)?* Yes No Other Training (graduate, technical, vocational):*Please indicate any current professional licenses or certificates that you hold:*Awards, Honors, Special Achievements:*Military Service?* Yes No Branch:* Specialized Training:*Reference #1* List 2 non-relatives who would be willing to provide a reference for you.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Telephone:*Relationship:* Reference #2* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Telephone:*Relationship:* Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:*CAPTCHA
