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Family Resource Center Internship Application
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Family Resources Center Internship Application
P. O. Box 188
Rocky Mount, VA 24151
24 Hour Hotline: 540-483-1234
Phone Number where you would prefer to be reached
Date of Birth
Date of Birth
Are you a U. S. Citizen?
Do you have a valid Virginia Driver's License?
How did you hear of the Family Resource Center Internship Program?
Have you ever been convicted of a felony?
Have you ever been charged with assault and battery?
Are you a "survivor" of domestic violence?
Have you ever been homeless?
Do you speak a foreign language?
If you speak a foreign language, please specify language/languages.
What is your highest level of education?
Case Management Choices (you may choose more than one)
Emergency Contact Person
If you chose Other in the previous question, please specify what type of case management you are interested in.
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