First Name:  *

Middle:

Last Name:  *

Birthdate (optional):

Social Security #:

City:  *

State:  * Alaska  Alabama  Arkansas  Arizona  California  Colorado  Connecticut  District of Columbia  Delaware  Florida  Georgia  Hawaii  Iowa  Idaho  Illinois  Indiana  Kansas  Kentucky  Louisiana  Massachusetts  Maryland  Maine  Michigan  Minnesota  Missouri  Mississippi  Montana  North Carolina  North Dakota  Nebraska  New Hampshire  New Jersey  New Mexico  Nevada  New York  Ohio  Oklahoma  Oregon  Pennsylvania  Puerto Rico  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Utah  Virginia  Vermont  Washington  Wisconsin  West Virginia  Wyoming 

Zip:  *

Email:  *

Phone:  *

City:  *

State:  * Alaska  Alabama  Arkansas  Arizona  California  Colorado  Connecticut  District of Columbia  Delaware  Florida  Georgia  Hawaii  Iowa  Idaho  Illinois  Indiana  Kansas  Kentucky  Louisiana  Massachusetts  Maryland  Maine  Michigan  Minnesota  Missouri  Mississippi  Montana  North Carolina  North Dakota  Nebraska  New Hampshire  New Jersey  New Mexico  Nevada  New York  Ohio  Oklahoma  Oregon  Pennsylvania  Puerto Rico  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Utah  Virginia  Vermont  Washington  Wisconsin  West Virginia  Wyoming 

Zip:  *

Email:  *

Phone:  *

Name of College/University Advisor:  *

Title:  *

Address:  *

City:  *

State:  * Alaska  Alabama  Arkansas  Arizona  California  Colorado  Connecticut  District of Columbia  Delaware  Florida  Georgia  Hawaii  Iowa  Idaho  Illinois  Indiana  Kansas  Kentucky  Louisiana  Massachusetts  Maryland  Maine  Michigan  Minnesota  Missouri  Mississippi  Montana  North Carolina  North Dakota  Nebraska  New Hampshire  New Jersey  New Mexico  Nevada  New York  Ohio  Oklahoma  Oregon  Pennsylvania  Puerto Rico  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Utah  Virginia  Vermont  Washington  Wisconsin  West Virginia  Wyoming 

Zip:  *

Email:  *

Phone:  *

Major:  *

When do you expect to graduate?  *

Will you have access to a vehicle? (car, truck, motorcycle)?  * Yes  No 

If yes, what type?

Length of internship required by the College/University - (KADEP requires 15 weeks):  *

Preferred start date:  *

Preferred ending date:  *

Did you read and understand internship information and dates?  * Yes  No 

Please summarize briefly your work/volunteer experience with individuals with disabilities.

Address (included City and State):

Phone:

Start Date:

End Date:

Brief description of duties:

Address (included City and State):

Phone:

Start Date:

End Date:

Brief description of duties:

Address (included City and State):

Phone:

Start Date:

End Date:

Brief description of duties:

Address (included City and State):

Phone:

Start Date:

End Date:

Brief description of duties:

List your goals for your internship experience:

Provide a statement of your career objective:

Are you available for a personal interview?

If so, when?

How did you hear about the King Adult Day Enrichment Program?