Thank you for your interest in volunteering at Maude Kerns Art Center!

Internship Application Form

Date:______________      

Name ______________________________________________________________

Address ____________________________________________________________

City ___________________ State ____________ Zip ________________________

Home Phone _____________________ Work Phone __________________________

Email___________________________________________________

Have you been convicted of a felony in the past five years? ________Yes ________ No

If Yes, please explain: _________________________________________________________

_____________________________________________________________

Are you a student? ______ Yes ______ No       Date of Birth: ______________________

            What school do you attend? ____________________________________

            What grade or year are you in? _____________________________________

Have you done internship work at another non-profit? ______ Yes  ______ No

            If yes, where and what did you do? ___________________________________

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What type of work would you like to do here? ___________________________________

__________________________________________________________________

List any hobbies, talents, or interests: _________________________________________

______________________________________________________


What skills, training, or knowledge do you wish to utilize here? ___________________

___________________________________________________________________

Why do you want to become intern here? ________________________________________

___________________________________________________________________

Where did you hear about Maude Kerns Art Center? ___________________________

 



When are you available to volunteer?  Please be as specific as possible.

Monday Tuesday Wednesday Thursday Friday
         

For how long will you be able to work as an intern? __________________________________

If you have a disability, what accommodation would you need to do this internship position?

___________________________________________________________________

What training, resources, or support do you anticipate needing to do this internship work?

___________________________________________________________________

Please provide 3 personal or professional references:
 

Name Phone Number Relationship
  (       )             -  
  (       )             -  
  (       )             -  

 I hereby attest that the following is true to the best of my knowledge.


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Signature
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Today's Date

** If you are chosen for internship work, please complete the following **

In case of emergency, please contact:

Name: __________________________ Phone (W) ___________ (H) ____________

Medical Information we should be aware of in case of emergency (allergies, special medications, &/or conditions): ____________________________________________

___________________________________________________________________

Mail to or Drop off at:

Maude Kerns Art Center
1910 E. 15th Avenue - Eugene, Oregon 97403