TEAM Interest Form

Name*
First Last
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Semester Requested*
Position of Interest*
For students interested in practicum placement, what number practicum placement is this?*
Please indicate the practicum for which you are applying:*
If you selected other to the question above, please type practicum here:*
Are you currently studying any of the following?
- Applied Behavioral Analysis (ABA)
- Speech & Language Pathology
- Social Work
- Sports and Recreation
- General Autism Internship Experience (non-specific to a discipline)
- Marketing and Development
- Professional Observership Program (Fee-based program)
- Other
Expected graduation date:
MM slash DD slash YYYY
Degree of diploma:
Previous Work Experience
List all clinical related work experience (include company/organization name and job title/description):*
How many documented clinical hours do you expect to have when you begin this practicum experience?*
How many documented clinical hours have you had specific to Autism Spectrum Disorder?*
How many documented clinical hours have you had specific to pediatrics in the field of ASD?*
How many documented clinical hours have you had specific to adults with ASD?*
Upload Cover Letter and CV/Resume*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB, Max. files: 4.
Please provide supporting documentation with your application.

Previous Work Experience