Last Name

First Name

Middle Name

Mailing Address:

Alternate Mailing Address:

Email Address:

Phone Number

Username

Date of Birth

Sex

City

State

Citizenship

Race(optional)

Tribe(optional)

Institution Name

Institution Size

Major

Minor or Certificate
(if any)

Program Dates

What are the dates of your summer break?

Research Interest

Science

Technology

Engineering

Mathematics

Have you had previous Internship experience? Yes No

When

Where

What are your long and short term educational goals?

Length of desired internship

Are you able to participate in an Internship Virtual Fair? Yes No

Geographical preference:

Region

Parental Education

Please select the highest level of education completed.

Mother

Father

Medical Information

Do you have any health conditions that may interfere with performing an internship requiring outdoor/physical activities (e.g., allergies or physical limitations)? Yes No

(if yes, please explain)

Do you have medical/health insurance? Yes No