Internship Form

Thank you for showing an interest in NAMI of Central Georgia. NAMI is America’s largest grassroots organization dedicated to improving the lives of individuals and families affected by mental illness. NAMI of Central Georgia is the only NAMI affiliate owned and operated in state, non-profit, licensed group home dedicated to serving individuals and families affected by mental illness.

Please read the internship form closely, included you will find the following:

Student Internship Application
Intern information and code of conduct
Confidentiality and release of liability forms
GBI consent for criminal background check
General task list

In addition to the attached paperwork, student interns will be required to pay for the following items:

Background Check $17.00
Drug Test $30.00
NAMI Membership $40

Additional requirements include a TB skin test. This is your responsibility. Please consult your primary care physician, Health Department and/or other agencies such as Macon Occupational Medicine.

All Student Interns are required to wear scrubs and closed-toe shoes while working onsite. Scrubs may be purchased at Goodwill or any medical clothing establishment. Any color or pattern is permitted.

Please fill out the information attached and return as soon as possible. Once your information is received, an interview will be set up by our Executive Assistant.

Call or email us should you have ANY questions or concerns! Be sure to visit us on our Facebook page. We look forward to providing you with a great educational experience.

Name(Required)

First Middle Initial Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Alternate Phone

Email(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Relationship

Emergency Contact Primary Phone(Required)

Emergency Contact Alternate Phone

Advisor / Professor Over Internship(Required)

Advisor / Professor's Email(Required)

Advisor / Professor's Phone(Required)

Estimated Dates of Internship(Required)

Semester Completing Internship(Required)

How Did You Hear About NAMI of Central GA?

Availability(Required)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Please list the hours you are available. Use N/A to indicate the day(s) you will not be available

Note:

Typical internship hours are Monday through Friday 8:00 am – 4:00 pm. Weekend and alternative hours must be approved by an administrator.

Education(Required)

High School, College, Technical School

City, State

Major/ Program of Study

Degree or Certificate Obtained

Please state your education history. You can add more rows using the plus (+) icon.

Internships

College / Technical School

City, State

Organization

Dates

Please list any past internships you have completed. You can add more rows using the plus (+) icon.

Work History

Name of Employer

City, State

Position(s) Held

Dates of Employment

Please list your current and past work history. You can add more rows using the plus (+) icon.

Volunteer Experience

Organization

City, State

Position / Event

Dates

Please list any past volunteer experience including church, community, or non-profit activities. You can add more rows using the plus (+) icon.

Other Relevant Skills

Include any technical skills, professional licenses, certifications, other languages spoken, etc.

References

Name

Phone Number

Relationship to You

Please list two references.

Media Release Consent

I, the undersigned, do hereby grant or deny permission to NAMI of Central Georgia to use my image as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the NAMI of Central Georgia website.

Grant or Deny Permission(Required)

Deny permission to use my image at all.

Grant permission to use my image in the following ways:

Mark all that apply:

Limited usage: I want my image used within the NAMI of Central Georgia setting only (not in the larger community).

Limited usage: I want my image used for educational materials only (not marketing). This could be either within NAMI of Central Georgia or in the larger community. One example of this could be videos in education classes.

Limited usage: I want my image used on printed materials only (no digital or video use).

Unrestricted usage: I give unrestricted permission for my image to be used in print, video, and digital media. I agree that these images may be used by NAMI of Central Georgia for a variety of purposes and that these images may be used without further notifying me. I do understand that my last name will not be used in conjunction with any video or digital images.

Confidentiality Policy

Welcome to NAMI Central Georgia, Inc.,

We are pleased to have you intern with us and participate in our programs, services, and activities. As an intern, it is important you understand and abide by NAMI Central Georgia, Inc.’s strict policy of consumer confidentiality. This policy is interpreted to include strict limitations regarding information about consumers, employees, and the business of the agency. In addition, this policy is extended to members attending support groups.

During your internship, you may observe or come into contact with consumers and/or information about consumers and/or employees of NAMI Central Georgia, Inc. You are required to hold any awareness of individuals and related information in confidence. This form will serve as acknowledgement and acceptance of NAMI Central Georgia’s policy and guidelines regarding confidentiality.

Signature(Required)

Type in your name.

Today's date(Required)

Background Check(Required)

Price:

Drug Test(Required)

Price:

Nami Membership(Required)

Price:

Total

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Maestro

Card Number Expiration Date Security Code Cardholder Name