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2. Family Resources Center Internship Application
   P. O. Box 188
   Rocky Mount, VA 24151
   Phone: 540-483-5088
   24 Hour Hotline: 540-483-1234
4. Today's Date*
   Today's Date
5. Name*
7. Address*
8. 2nd Address
10. City*
11. State*
12. Zip Code*
14. Phone Number where you would prefer to be reached*
15. Email Address
17. Date of Birth
    Date of Birth
18. Current Age*
19. Are you a U. S. Citizen?*

    1. Yes
    2. No
20. Do you have a valid Virginia Driver's License?*

    1. Yes
    2. No
22. How did you hear of the Family Resource Center Internship Program?*
24. Have you ever been convicted of a felony?*

    1. Yes
    2. No
25. Have you ever been charged with assault and battery?*

    1. Yes
    2. No
26. Are you a "survivor" of domestic violence?*

    1. Yes
    2. No
28. Have you ever been homeless?*

    1. Yes
    2. No
29. Do you speak a foreign language?*

    1. Yes
    2. No
30. If you speak a foreign language, please specify language/languages.
32. What is your highest level of education?*
34. Case Management Choices (you may choose more than one)*

    1. Babysitting
    2. Transportation
    3. Women's Activities
    4. Children's Activities

    1. Emergency Contact Person
    2. Group Facilitator
    3. Office Help
    4. Other
35. If you chose Other in the previous question, please specify what type of case management you are interested in.
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field