- TCC

First Name*

Last Name*

Street Address*

City*

State*

Zip*

Phone Number*

Email*

Date of Birth*

Have you ever been convicted of a criminal offense or been listed on the misconduct registry?*

Are you or any family members receiving services at TCC?*

Have you lived outside the state of Texas in the last two years?*

Days Available (choose all that apply)*

Preferred Hours (choose all that apply)*

Program of Interest*

Current Level of Education*

School

Program/Major

Field of Interest

Semester/Dates of Interest

Please provide name of preceptor (if applicable)

Do you speak any other languages other than English?

If yes, what language(s)?

Are you a current Employee?

Number of Hours Required

Beginning and end dates of semester

We will only provide supervision for a minimum of 2 semesters as the time commitment required puts a strain on Center resources.

I understand that I will be held to the highest professional standards while in this practicum/internship. I acknowledge that I have answered all questions truthfully and to the best of my knowledge. By clicking on submit, I understand that I will also be required to pay for my required CPR/First Aid training (cost is $24.00) and maintenance CPR training BEFORE beginning this internship experience. If at any time I am unable to complete my requirements, I understand that the Center reserves the right to cease my internship/practicum immediately and will notify my institution immediately.