Marketing and Development Internship Application

Complete the form below by using your mouse or pressing the tab key to move between fields.  When completed please click the 'Submit' button or press enter to forward your internship application to the Hickok Center.

Marketing and Development Internship Application
Full Name:           Date:   

City:          State:          Zip:

Primary Telephone Phone:         Work        Home

Secondary Telephone Phone:         Work        Home

Email Address - Primary:
Email Address - Secondary:

College or University:
Year:         Major(s):         GPA: 

Language(s) Spoken:

Have you ever been convicted of or pleaded no contest to a felony within the last five years?
Yes        No
If yes, please explain:

During which hours are you available for internship assignments? Center Hrs. of Operation (8:00 a.m. – 4:00 p.m./weekend/evening variability) Please CHECK days available:

Weekday Mornings                 Mon    Tue    Wed    Thu    Fri        Times: 

Weekday Afternoons                 Mon    Tue    Wed    Thu    Fri        Times: 

Weekends                 Sat    Sun        Times: 
*We have a few weekend events such as festivals and fundraisers throughout year.

Marketing                    School and Grade level:
Public Relations            School and Grade level:
Business                      School and Grade level:
Not-For-Profits             School and Grade level:
Development                School and Grade level:

Special Skills or Qualifications Summarize special skills and qualifications you have acquired from academia, employment, previous volunteer work, or through other activities, including hobbies or sports. Please attach your resume.

Previous Experience Summarize your previous internship experience or community work. ?????

I   DO / DO NOT have my own laptop with internet capabilities to bring with me to the internship. (This will NOT affect your eligibility for the program.)

Person to Notify in Case of Emergency
Street Address:
City: , State: , Zip Code:
Home Phone:  
Work Phone:  
E-Mail Address:  

Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as an intern, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I agree to complete requirements for health screening/immunizations and provide results to the Hickok Center. I also agree to:
(1) Hold as absolutely confidential all information which I may obtain directly or indirectly concerning Hickok Center members/participants or personnel (Confidentiality Agreement attached).
(2) Uphold the Core Values and Mission of the Hickok Center for Brain Injury

Name (printed):
Signature** (see below)

Our Policy: It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.  Thank you for completing this application form and for your interest in interning with us. Please click Submit or press Enter to send your application to the Hickok Center.


Please click Submit above or return this completed application, with your cover letter explaining your career goals and your interest in the internship, brief but concise resume and at least one faculty letter of recommendation by snail mail, fax or email (recommended) to:

Gabrielle Hewson
Director of Marketing and Development
Hickok Center for Brain Injury, Inc.
114 South Union Street
Rochester, New York 14607
Fax: 585-271-8688

** If submitting by email, your electronic signature is valid if coming from your personal email address. You will be asked, upon acceptance into internship program, to provide a tangible signature.

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