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?*YesNoAre you or any family members receiving services at TCC?*YesNoHave you lived outside the state of Texas in the last two years?*YesNoDays 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 SchoolProgram/MajorField of InterestSemester/Dates of InterestPlease provide name of preceptor (if applicable)Do you speak any other languages other than English?YesNoIf yes, what language(s)?Are you a current Employee?YesNoNumber of Hours RequiredBeginning and end dates of semesterWe 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.