Internship Application

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Name
First Last
College / University Attending
Major / Concentration
Anticipated Year Of Graduation
Internship Department At Chrysalis Center
Hours Per Week
School Address
Street Address Address Line 2 City State ZIP Code
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date of Birth
MM slash DD slash YYYY
Emergency Contact
Emergency Contact Name
First Last
Emergency Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
My Qualifications For This Position, Including Education & Work experience
Upload Resume
Max. file size: 256 MB.
I freely offer my services as an intern at the Chrysalis Center, Inc. I understand I will not be considered an employee of Chrysalis Center for any purposes and am aware I am not entitled to any compensation or benefits. I acknowledge that Chrysalis Center reserves the right to discontinue my services at any time. It is expected while serving as an intern at Chrysalis Center I may be given access to confidential information. I agree I will always safeguard that information and will not disclose such information to anyone other than authorized Chrysalis staff. I will fulfill all my duties in a professional and respectful manner while at Chrysalis Center. Finally, I agree to hold Chrysalis Center, any agent, employee, client, volunteer, and/or other intern, harmless for any injury to me or damage to my property that occurs while I am a intern at the Chrysalis Center, including any claims for negligence.*
- Yes
I grant permission to Chrysalis Center the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, and my story for the purpose of publication, either in print or social media. I hereby release Chrysalis Center and its legal representatives from all claims and liability relating to said images or videos. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for advertising and publicity without restriction. I waive my right to any compensation. I acknowledge that I am over the age of 18. I understand that I can revoke this Authorization, at any time, upon written request, except to the extend that a photo or printed information has already been printed or published in reliance upon it.*
- Yes
- No
***IF ONSITE*** As an intern at Chrysalis Center, Inc., I hereby acknowledge that I have been fully vaccinated against the COVID-19 virus and agree to bring a copy of my vaccination record with me on the first day of interning. I acknowledge that Chrysalis Center organization is doing everything they can to protect the public as well myself as a intern. To this extent, I agree to follow Center of Disease Control and local health district guidelines and Chrysalis Center’s policies and procedures for social distancing to reduce the spread of COVID-19. I understand that there is no direct medical health coverage afforded to me during my relationship with Chrysalis Center, Inc and said organization is not responsible for any potential exposure to COVID-19. By checking yes, I agree to comply with the instructions above. Failure to comply with these instructions or verbal instructions from staff may result in my intern privileges being removed and I may be asked to leave the premises.
- Yes
- No
Signature*
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