Date ______________________
Name_________________________________________________
Address________________________________________________
City____________________________________________________
 State________________________ZIP_______________________
Home phone_______________________________________________
Work phone ______________________________ ok to call here? 
Yes___No___
E mail:_______________________________________ 
Name of College or 
University______________________________________________________ 
Your major or concentration_______________________  
Current degree__________________  

I am studying for my ____ Masters	____ for your Doctorate 
I am applying for an internship with a focus on:
Trafficking prevention through public information
Research on trafficking
Safe-house Development 
Aid to victims
Trafficking law
Other (specify)

Briefly describe your internship goals

What is your time frame for an Angel Coalition internship?
(list from what month to what month)__________________________________________ 
Will this internship be for academic credit ____yes	___no
 Site preference:  Moscow______St. Petersburg__________other_______________________ Russian language skills:  none basic  intermediate fluent____
(Russian language skills are required at all Angel Coalition sites). 
 What computer programs do you work with____________________________________ __________________________________________________________________ 
Describe your academic experience (most recent first—not a resume, but what you did/learned) 
Why would you like to intern with The Angel Coalition in Russia? 

Health History 
You will be working in a foreign country with poor medical access. We do need to know about your health and any special needs.  Because you will be working in a foreign country, with minors, we need a security check to protect the children we/you work with and our organization)
Name of personal     health care professional
 _________________________________________________________________

Address ___________________________________________________________ 
City ____________________________ State _____________ZIP_____________

Please contact this person and authorize him/her to verbally release information about your general health status and ability to spend a summer in rural Russia—with medication (we need to know what you need!) if necessary. We will only inquire about your current state of health, ability to work and travel overseas, and current medications.  We are NOT asking for anything written or a “transcript” of your medical history. 

Security Check
We will call appropriate local, state and federal authorities to ensure that your passport status is valid and that any past/current involvement with the criminal justice system will not adversely affect your service.  This is done to protect the members of the Angel Coalition and victims receiving assistance through member organizations.  None of this information will be shared with anyone other than staff directly involved in decision-making regarding volunteer recruitment for the Angel Coalition. 
Name of local police department/precinct/station______________________________________________________ 
 Address____________________________________________________________ 
             City______________________________________ 
             State__________________ZIP_________________         

Permissions and Release of Liability 
I hereby give my permission for the Angel Coalition to call my personal health care provider to receive verbal information about my current health status and medications.  I agree to hold harmless, the Angel Coalition, its employees, Board of Directors and regional partners for any and all accidents and injuries that may occur during my volunteer service as an Angel Coalition volunteer in Russia. 
Signed______________________________________Date_______________ 
Print your name__________________________________________________