Full Name *

Address *

City/State/Zip *

Phone Number *

Email Address *

Last 4 digits of your social security number *

Date of Birth *

Education

University / College Currently Enrolled *

Program of Study

Highest level of education completed * HS Diploma Associates Degree Bachelors Degree Masters Degree

Degree you are currently seeking * Associates Degree Bachelors Degree Masters Degree

Contact Information for your school's Internship Director: (Name, Address, & Phone Information) *

Internship Requirements

Does your school require Philhaven to provide you with a supervisor at the Master's level? * Yes No

Does your school require you to have a clinically licensed supervisor? * Yes No

What is the total number of hours your internship requires for your semester? *

Check the following areas of interest Children Adolescents Adults

Availability

How many hours per week do you need for your internship experience? *

What shifts are you available? * Day Shift (8AM - 4PM) Mid Shift (12PM - 8PM) Evening (3PM - 11PM) Night (11PM - 7AM)

What days are you available? Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Starting date for your internship:

Completion date for your internship: *

Preferred Location Any Location Lancaster County Lebanon County York County

Employment Questions

Have you ever been convicted of a felony? * Yes No

Have you ever filed an application with us before? * Yes No

Have you ever been employed with us before? * Yes No

Are you prevented from lawfully becoming employed in this country because of VISA or Immigration Status? * Yes No

Authorization for Release of Information

I hereby authorize the release to WELLSPAN PHILHAVEN of any and all information relative to my internship, including but not limited to dates of employment, attendance records, performance ratings, rates of pay and eligibility for reemployment. I authorize its release without penalty or liability. A printed copy of this authorization shall be considered as valid as the original.

Electronic Signature *

Today's Date *

Personal Reference (No relatives or previous supervisors)

Name *

Address *

City/State/Zip *

Phone Number *

E-mail Address *

Professional Reference (No Relatives)

Name *

Address *

City/State/Zip *

Phone Number *

E-mail Address *

Authorization

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for internship as may be necessary in arriving at an internship decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any internship relationship with this organization is of an "at will" nature, which means that the intern may resign at any time and the organization may end the internship at any time with or without cause. It is further understood that this "at will" internship relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization. In the event of internship, I understand that false or misleading information given in my application or interview(s) may result in ending the internship. I understand, also, that I am required to abide by all rules and regulations of the organization.

Electronic Signature (Type your full name to indicate agreement) *

Today's Date *

WellSpan Philhaven Application Supplement

In a few sentences, how would you describe your preferred work environment?

Describe your understanding of mental illness.

Describe one characteristic that you value in yourself and why.

How have you handled the least interesting or least pleasant tasks assigned to you?

How do you cope with sudden deadlines and changes in your workload?

What distinguishes a great employee from a good employee?

How will you contribute to WellSpan Philhaven's mission?

Resume *

Upload a copy of your resume above. You may also email your resume to Daryl Groff (dgroff3@wellspan.org).