Last Name

First Name

Middle Name

Mailing Address:

Alternate Mailing Address:

Email Address:

Phone Number

Username

Password

Confirm Password

Date of Birth

Sex

City

State

Citizenship

Race(optional)

Tribe(optional)

Institution Name

Institution Size

Major

Minor or Certificate
(if any)

Program Dates

From   To

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:

City

State

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

Verification of Honesty and Truth

By typing my last name here, I certify that all of the statements and information provided in my application materials are true to the best of my knowledge.
  

Permission to Contact Instructors and Advisor

By typing my last name here, I give the SDC Office permission to contact my current or past instructors, advisors, and employers in regards to my performance in past/on-going related coursework/employment and my current academic standing within my institution.