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Application for Recreational Therapy Internship
Applicant Full Name:
*
Home Address:
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Number of years at this address:
*
Daytime Phone Number:
*
Evening Phone Number:
*
Mobile Phone Number:
*
Social Security Number:
*
Driver's License (State/Number):
*
Who should be contacted if you are involved in an emergency?
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(Contact Name)
Relationship to you:
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Address:
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Daytime Phone Number:
*
Evening phone number:
*
Who referred you to our company?
*
Do you have any friends or family who work here?
*
Yes
No
If yes, please list here:
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Have you applied to our company previously?
*
Yes
No
If yes, when?
*
Are you at least 18 years old?
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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:
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If applicable, are you available to work overtime?
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Yes
No
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?
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Yes
No
Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?
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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:
*
Skill #1:
*
List any skills that may be useful for the job you are seeking.
Skill #1 - Years of Experience:
*
Rate Ability for Skill #1:
*
(1 represents poor ability, 5 represents exceptional ability)
1 - Low
2
3
4
5 - High
Skill #2:
*
Skill #2 - Years of experience:
*
Rate Ability for Skill #2:
*
(1 represents poor ability, 5 represents exceptional ability)
1 - Low
2
3
4
5 - High
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):
*
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):
*
Name of College/University Attended:
*
Address of College/University Attended:
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Have you graduated?
*
Yes
No
Degree received:
Date of graduation:
*
Are you an active Certified Therapeutic Recreation Specialist (C.T.R.S.)?
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Yes
No
Are you a member of the American Therapeutic Recreation Association (ATRA)?
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Yes
No
Other Training (graduate, technical, vocational):
*
Please indicate any current professional licenses or certificates that you hold:
*
Awards, Honors, Special Achievements:
*
Military Service?
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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:
*
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