Work Study and Internship Application
* Required Fields
Your Contact Information
* First Name 
* Last Name 
* Current Address 
* City 
* State/Province 
* Zip/Postal Code 
  Home Phone 
  Mobile Phone 
  Work Phone 
* Email 
* Date of Birth 
* Social Security (required for all background checks) 
  College or University 
  Major/Concentration   Degree awarded or working toward 
  Graduation or anticipated Graduation Date 
  Have you been a member, or a volunteer or employed at any Boys & Girls Club?   If yes, where and when: 

Internship Information
  Internship(s) for which you are applying - check all that apply:   Marketing & Resource Development 
  Event Planning & Volunteer Management   Sports, Fitness & Recreation Programs 
  The Arts Programs   Education & Career Development Programs 
  Academic Intervention Intern 

  Spring (January - April)   Summer (June - August) 
  Fall (September - December)   Are you seeking academic credit for this internship? 
  If seeking academic credit, interns are responsible for obtaining and meeting their specific program requirements. We will provide necessary documentation for credit upon request. 

  Please list the days and times you are available: 
  Mon AM   Mon Afternoon   Mon PM 
  Tue AM   Tue Afternoon   Tue PM 
  Wed AM   Wed Afternoon   Wed PM 
  Thu AM   Thu Afternoon   Thu PM 
  Fri AM   Fri Afternoon   Fri PM 
  Sat AM   Sat Afternoon 

Additional Information
  Do your currently use illegal drugs?   If yes, please explain here: 
  Have you ever been convicted of child abuse or neglect or is there a pending charge against you for child abuse or neglect?   If yes, please explain here: 
  Have you ever been convicted of a criminal offense?   If yes, please explain here: 

Personal Statement
  Please write a statement addressing your academic and career goals. Please keep statement to 1/2 or 1 page: 

Relevant Work
  Please provide relevant work and coursework experiences and other experience that relate to the internship: 

  Understanding and Authorization: 
  I certify that all the answers on the application and any attachments are true and complete to the best of my knowledge. I also certify that I have not withheld any pertinent information. I agree that in the course of considering my application, you may inquire to verify information considering my background. I specifically authorize you to investigate all statements in the application. I authorize educational institutions, employers and references listed above to give you any and all information concerning my education, employement and fitness to work with children and young people. 
  I further agree to release and hold harmless the Boys & Girls Clubs, institutions, references listed above and any law enforement agencies from all liability and any damage that may result from furnishing this information to you. 
  I certify this statement 

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Contact Us:  Boys & Girls Clubs •• 701 N. Raleigh Blvd. Raleigh, NC  27610 •• 919/834-6282 ••

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