Internship Re-Application

Complete this form and select "Submit Application" at the bottom of the form. Your application data will be emailed to the Washburn University Human Services Department.

Applicant Data

Term for Placement Fall Spring Summer       Year
First & Last Name


Mailing Address
Daytime Phone
Evening Phone
MyWashburn E-mail Address**
Faculty Advisor

Notice: Your Washburn University e-mail address will be the official address used by the University for relaying important messages regarding academic information, including internship. It may also be used by your instructors to provide specific course information. E-mail messages sent to your Washburn University e-mail address will be considered your official notification for important information.

Current Classification

Area of Concentration (Check One)
Addiction Counseling (AO)
Adult Care Home Administration (ACHA)
Developmental Disabilities (DD)
Gerontology (GR)
Mental Health (MH)
Non-profit Management (NP)
Victim/Survivor Services (VS)
Youth Services (CC)

This internship is needed to complete my (choose one)
BAS AAS Certification

Expected Term of Completion
Summer Fall Spring        Year
Distance students are given enrollment priority for online seminars.
Are you requesting to be considered for an online seminar?
If yes, please select your specific reason(s):
      Live at a distance
           (Where? )
           (Specific days worked and hours worked )
          (Explain: )
Days available for internship (select all that apply):
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Times available:
AGENCIES (for Previous Internships Completed)

HS 280 (Internship I)
HS 281 (Internship II)
HS 380 (Internship III)
HS 381 (2 + 2 PLAN only)

Please indicate agencies or areas of interest (such as children, aging, mental health, etc.) that you desire in a field placement:

If you are applying for a Summer internship, please tell us why you need a summer internship and how it affects your graduation plans.



  • March 1 for Summer Semester AND March 1 for Fall Semester
  • October 1 for Spring Semester

By submitting this form, I agree that I have read and understand the academic and clinical policies set forth in the Human Services Department Internship Manual and agree to abide by these requirements and appropriate agency requirements. I understand that I have responsibilities as a student in this program and that I may be dismissed from the internship placement and possibly the Human Services program if I disregard these policies or ignore my responsibilities as a student in the educational process.

Print the confirmation of the online-submitted application for your records and to verify submittal.