Internship Form

Thank you for considering CenClear for your Internship/Supervision experience. Prior to participating in an Internship/Supervision at CenClear you will be required to have obtain the following clearances: · PA Criminal Record (State Police)- https://epatch.state.pa.us · Child Abuse History Check- www.compass.state.pa.us/cwis · FBI Clearance- PA Department of Human Services - https://uenroll.identogo.com · Mandated Reporting Certificate-free-www.reportabusepa.pitt.edu. Please answer the questions thoroughly. If a question does not apply to your request please write N/A in the answer box.

1.	First Name:*

2.	Last Name:*

3.	Address:*

4.	Phone Number:*

5.	Email:

6.	Department you wish to complete an Internship/Supervision in: Please indicate which department you wish to complete an Internship/Supervision in:
	Early Head Start    Preschool    Mental Health    Drug and Alcohol    Other, please specify

7.	Date of Internship/Supervision Required/Requested:*

8.	Number of Hours Required: (If a set number is not required, please note that)*

9.	Supervision Requirements: (If no requirements, please list N/A)*

10.	Degree You Are Working to Obtain and Concentration: (If you are not working towards a degree, please note that.)*

11.	Have You Ever Worked for CenClear before:*
	--Please Select--Yes No

12.	If you answered "yes" to question 11, please indicate the position you held with CenClear and the dates you worked for us.

13.	Name, phone number and email address of School Contact Person, if applicable: