Internship Form

First Name

Middle Name

Last Name

Nickname

Street Address

City

State

Zip

School Name

Current Grade

Birthdate (MM/DD/YY)

Email of Student

Phone of Student

Emergency Contact Name

Emergency Contact Phone

Parent/Guardian Name

Home Phone

Work Phone

Cell Phone

Additional Information

Would you be interested in a possible need-based scholarship?

Yes
No

Have you ever been suspended from school for any reason?

Are there any medical problems, special needs, or concerns that the staff needs to be aware of?

No
Yes (If yes, please explain below)

Liability Release:
By submitting this internet form, I hereby forever release Cardinal Rep., a non-profit corporation, organized and existing under the laws of the State of Georgia, its agents, directors, officers, servants, employees, volunteers, staff, and independent contractors from any and all costs, claims, losses, liabilities or damages arising from or in any way related to, my service either as an agent, director, officer, servant, employee, volunteer, staff member, or independent contractor of Cardinal Rep. I intend this release to be effective, regardless whether the claim of liability is asserted in negligence, strict liability in tort, or other theory of tort recovery.

Personal Information
First Name	Middle Name	Last Name	Nickname

Street Address	City	State	Zip

School Name		Current Grade	Birthdate (MM/DD/YY)

Email of Student	Phone of Student	Emergency Contact Name	Emergency Contact Phone

Parent/Guardian Name	Home Phone	Work Phone	Cell Phone

Additional Information
Would you be interested in a possible need-based scholarship?
Yes No
Have you ever been suspended from school for any reason?		Are there any medical problems, special needs, or concerns that the staff needs to be aware of?
No Yes (If yes, please explain below)		No Yes (If yes, please explain below)

Liability Release: By submitting this internet form, I hereby forever release Cardinal Rep., a non-profit corporation, organized and existing under the laws of the State of Georgia, its agents, directors, officers, servants, employees, volunteers, staff, and independent contractors from any and all costs, claims, losses, liabilities or damages arising from or in any way related to, my service either as an agent, director, officer, servant, employee, volunteer, staff member, or independent contractor of Cardinal Rep. I intend this release to be effective, regardless whether the claim of liability is asserted in negligence, strict liability in tort, or other theory of tort recovery.