APPLICATION FOR INTERNSHIP
CITY CROSSROADS MINISTRY
(Please Print)
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Last name First name MI Birth Date
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Address City State Zip
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Soc Sec # Telephone Email
* On what date are you available to begin? ______________________
* On what date would you need to leave? _______________________
* Do you have a valid driver's license? _________________________
* Are you certified in CPR? [ ] yes [ ] no First Aid? [ ] yes [ ] no
If yes please include expiration date__________________________
* Have you had any Driving Under the Influence of Drug/Alcohol offenses or moving violation
within the past ten years? [ ] yes [ ] no
If yes please explain:
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* Have you been convicted of a crime in the last 7 years or are any criminal charges currently
pending against you in any jurisdiction? (Conviction will not necessarily disqualify you)
[ ] yes [ ] no
If yes, please explain:
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The position you are applying for will require direct contact with and supervision of children,
therefore we must request the following information.
* Have you ever been convicted of, or any charges pending against you concerning any crime
involving actual or attempted child abuse or sexual molestation in any jurisdiction, including
but not limited to: murder, abduction for immoral purposes, sexual assault, failing to secure
medical attention for an injured child, pandering, crimes against nature involving children,
taking indecent liberties with children, neglect, or obscenity offenses? [ ] yes [ ] no
If yes please explain:
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Education:
Name Course of Study Years completed Diploma/Degree
High School ____________________________________________________________________
College _______________________________________________________________________
Other _________________________________________________________________________
Indicate any foreign languages that you can speak
Fluent Good Fair
speak
read
write
Describe any specialize training, apprenticeship, skills and extra-curricular activities.
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Statement of Qualification
In your own words, please share why you would like to be considered for a position with City
Crossroads and what qualifications you feel you would bring to this position.
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Statement of Faith
Please share a statement of your personal Christian experience. Please focus on your relationship
with Christ.
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Name of Church:___________________________ Pastor's Name:__________________
Address:__________________________________ Phone #:_______________________
Job/Volunteer Experience
________________________________________________ work performed __________
Employer/Organization dates
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Address
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Phone #
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Supervisor
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Reason for leaving
________________________________________________ work performed __________
Employer/Organization dates
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Address
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Phone #
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Supervisor
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Reason for leaving
________________________________________________ work performed __________
Employer/Organization dates
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Address
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Phone #
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Supervisor
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Reason for leaving
Please use the back of this paper if you need more room
References: Include 1 pastoral, 2 professional and 2 personal references – one must be from
someone in leadership from your church besides your pastor to whom you are accountable.
1. ____________________________________________________________________
name phone
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address relationship
2. ____________________________________________________________________
name phone
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address relationship
3. ____________________________________________________________________
name phone
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address relationship
4. ____________________________________________________________________
name phone
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address relationship
5. ____________________________________________________________________
name phone
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address relationship
APPLICANT'S STATEMENT
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 affirm that I have neither been convicted of, or am I the subject of pending charges for, any offense involving actual or attempted child abuse or sexual molestation in any jurisdiction.
I agree to be fingerprinted for a background check if asked.
I understand that this application shall be considered active for six months.
I understand and acknowledge that any internship relationship with this organization if of an "at will" nature, which means that the intern may resign at any time and that City Crossroads may discharge the intern 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 on e of the co-director of City Crossroads.
I understand that I will be required to work 24 hours each week. I also understand that the work will involve the hands on running of the center as well as but not limited to preparation, procurement, field trips, shopping.
I understand that City Crossroads will provide housing and meals while the center is open for operation. In exchange I agree to contribute a $250.00/mo. donation for the position. I agree to be responsible for my own personal needs and the cleaning of my room and shared space.
I agree to attend the First Church of God, San Francisco, to be a living example of meeting with the fellowship, and will do my best to encourage the youth and children from City Crossroads to attend a church also.
In the event of an intern relationship, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations governing the ethical and moral values of this organization.
Signature of applicant:__________________________________ Date: _____________ Print Name: ___________________________________________________________