CEIP Application

Civic Engagement Internship Program Application

An Experiential Learning Opportunity...Explore, Engage, Connect
Student Name*

First NameLast Name
SUSCC Student Number*
A#
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
SUSCC Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Are you currently enrolled in classes at SUSCC?

YesNo
What is the primary campus in which you attend classes?*

OpelikaWadleyValley
Do you have reliable transportation?

YesNo
Use the space below to upload current resume (PDF only).*

Cancelof
Use the space below to upload Unofficial College Transcript.*

Cancelof
Educational Goals (check one):*

Earn one or more certificates from SUSCCEarn an Associate of Applied Science degree from SUSCCEarn an Associate of Science degree from SUSCCEarn an Associate of Science degree from SUSCC and transfer to a four-year university to earn a bachelor's degreeOther
What is your desired college major or field of study?*
What is your long-term career goal?*
Expected Graduation (e.g. Fall 2022, Spring 2023, Summer 2023, etc.)*
Semester
Request one or more instructors email a letter recommending your participation in the civic engagement internship to tlaye@suscc.edu. Indicate in the space provided below the full name of the instructor(s) you have asked to provide a recommendation. Your application is not complete until instructor recommendation email is received.*
Instructor Name(s)
Using the space provided below, describe why you are interested in participating in this experiential learning opportunity.*
Using the space provided below, describe what you hope to gain through participating in this experience and how you see involvement in the community relating to your educational, professional, or personal goals.*
Using the space below, provide any additional information about you the committee needs to consider when selecting civic engagement interns.
Medical Insurance

Students are strongly encouraged to be covered by adequate health and accident insurance during a work experience. Southern Union State Community College will not be responsible for any accident/injuries which occur as part of the Civic Engagement Internship Program or other work-based learning experience. Students may not file for worker's compensation claims while participating in the program. Further, students may not apply for unemployment compensation at the close of the Civic Engagement Internship Program.

Your signature below acknowledges your understanding that neither Southern Union State Community College nor your work experience employer/job site will be responsible for any accident or injuries resulting from participation in the Civic Engagement Internship Program or other work-based learning experience.
Applicant Signature*

Clear
Read and sign below:

I understand that meeting the minimum program eligibility requirements and completing this application does not guarantee an internship placement. All application materials become the property of Southern Union State Community College and may be shared with prospective organizations.

It is the sole responsibility of the applicant to ensure that the College has received all required documentation to be considered for a Civic Engagement Internship placement.

I hereby certify that the information given in this application is true and correct. I understand that providing false information may be deemed sufficient reason to dismiss the student and/or refuse participation.
Applicant Signature:*

Clear
Date:*

MonthDayYear
Date
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Civic Engagement Internship Program Application