TCC Practicum & Intern Application Please complete the following information. All interns must be at least 18 years old and enrolled in a program listed on the TCC Volunteer site. 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?* Yes No Are you or any family members receiving services at TCC?* Yes No Have you lived outside the state of Texas in the last two years?* Yes No Days Available (choose all that apply)* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preferred Hours (choose all that apply)* Mornings Afternoons Evenings Program of Interest* Practicum Post Graduate Internship (LPC-A, LMSW-In LCSW Internship, LMFT-A) Current Level of Education* Undergraduate Graduate 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? Yes No If yes, what language(s)? Are you a current Employee? Yes No 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.