Agency & Contact Information

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* 1. Name of Community Agency

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* 2. Who is completing this form?

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* 3. Who is the person at the agency that will be leading the internship
Note: This person will be referred to the Agency Internship Leader.

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* 4. Agency internship leader's preferred pronouns 

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* 5. Agency internship leader's email address

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* 6. Is there someone co-leading this internship (e.g. a colleague at your agency; academic partner)?

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* 7. Please provide the contact information for the person co-leading the internship

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* 8. Has the internship leader participated in the AVA Triadic Mentorship Program (TMP)?

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* 9. If the agency internship leader or co-leader is currently participating in the AVA Triadic Mentorship Program, please specify the academic mentor’s name below.

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* 10. In point form, what skills or expertise does the Agency Internship Leader and Co-Leader (if applicable) possess, that will contribute to leading an intern in the AVA Community Internship Program (maximum 250 words).

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* 11. Agency internship leaders and co-leaders (if applicable) must read the AVA Community Agency Internship Overview document. This is required to submit the application.

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