Initiating Communities Helping Area Neighborhoods Gain Empowerment

Initiating Communities Helping Area Neighborhoods Gain Empowerment Initiating Communities Helping Area Neighborhoods Gain Empowerment

PO Box 81172, Lansing, MI 48908 • EIN: 45-4900740 • Board Intranet Login

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ICHANGE Internship Consideration Request

Apply for a clinical internship.

Complete every section below. Resume and cover letter required. Applicants will be tested for illegal drugs. A Central Registry check and full background check will be conducted. Your application is encrypted in transit; please review your responses carefully before submitting.

indicates a required field.

1 About you

First name *

Middle name

Last name *

Maiden name

Email *

Phone *

Street address *

City *

State *

ZIP *

Date of birth *

Social Security Number *

Format: 9 digits with or without dashes. Used for background check only.

2 Availability

Hours per week you can work *

Can you work nights? *

Yes No

Days/hours available to work *

3 Education

Complete the rows that apply.

High School

School / university name

Location (city, state)

Years completed

Major & degree

College

School / university name

Location (city, state)

Years completed

Major & degree

Trade School

School / university name

Location (city, state)

Years completed

Major & degree

Professional School

School / university name

Location (city, state)

Years completed

Major & degree

4 Legal disclosure

Have you ever been convicted of a felony or misdemeanor? *

Yes No

If yes — explain the conviction(s), nature of offense(s), when committed, sentence(s) imposed, and type of rehabilitation

Required only if you answered “Yes” above.

5 Skills & technology

Proficient with Microsoft 365?

Yes No

Comfortable using AI tools?

Yes No

Comfortable typing?

Yes No

Typing speed (WPM)

Technology platforms you have used

6 References

Please list two references other than relatives or previous employers.

Reference #1

Name *

Position *

Email *

Phone *

Reference #2

Name *

Position *

Email *

Phone *

7 Additional qualifications

Anything else you would like us to know about your qualifications for the student clinical intern position?

8 Military service

Have you ever been in the armed forces? *

Yes No

Are you currently a member of the National Guard? *

Yes No

Specialty (if any)

Date entered

Discharge date

9 Work experience — past 5 years

List your two most recent positions, beginning with the most recent. If self-employed, give firm name.

Most recent position

Name of employer *

Last supervisor’s name *

Address (street)

City, State, ZIP

Phone

Your last job title *

From (start date) *

To (end date or “Present”)

Starting pay/salary

Final pay/salary

Reason for leaving (be specific) *

Duties performed, skills used or learned, advancements or promotions *

Prior position

Name of employer *

Last supervisor’s name *

Address (street)

City, State, ZIP

Phone

Your last job title *

From (start date) *

To (end date or “Present”)

Starting pay/salary

Final pay/salary

Reason for leaving (be specific) *

Duties performed, skills used or learned, advancements or promotions *

10 Clinical experience — past 5 years

If self-employed or volunteer, give agency name.

Most recent clinical position

Name of employer or agency *

Last supervisor’s name *

Address (street)

City, State, ZIP

Phone

Your last job title *

From (start date) *

To (end date or “Present”)

Starting pay/salary

Final pay/salary

Reason for leaving (be specific) *

Duties performed, skills used or learned, advancements or promotions *

Prior clinical position

Name of employer or agency *

Last supervisor’s name *

Address (street)

City, State, ZIP

Phone

Your last job title *

From (start date) *

To (end date or “Present”)

Starting pay/salary

Final pay/salary

Reason for leaving (be specific) *

Duties performed, skills used or learned, advancements or promotions *

11 Documents

PDF, DOC, or DOCX. Max 8 MB each.

Resume *

Cover letter *

12 Final questions

May we contact your present employer? *

Yes No

Did you complete this application yourself? *

Yes No

If not, who completed it?

13 Waiver & electronic signature

In exchange for consideration of my application by ICHANGE, I agree that this application does not create an employment or contractual relationship, and that any future relationship can be ended as outlined in the service agreement.

I authorize ICHANGE to investigate all statements made in this application, contact my schools / previous employers / references, and I release ICHANGE from liability arising from that contact. I understand that misrepresentation or omission of facts is grounds for dismissal at any time without previous notice.

I understand that ICHANGE has a drug and alcohol policy with pre-employment testing, mandatory training in the first two weeks, and that consent to and compliance with these policies is a condition of consideration. I further understand that any internship with ICHANGE is on a contractual basis only.

I agree to the waiver above * I have read and agree to the waiver above.

I authorize a background check * I authorize a Central Registry check, full background check, and drug screening.

Electronic signature — type your full legal name *

Date *

Your application is encrypted in transit. Only the ICHANGE Intern Selection Team can view submissions.

Real Talk. Real Tools. Real Change.
Empowering our community with the tools, support, and guidance to thrive — together.

ICHANGE
PO Box 81172, Lansing, MI 48908
Office (810) 243-2607 · Fax (517) 853-2081
EIN: 45-4900740 · clientservice@ichangeprocess.org

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