EXTERN and INTERN PROGRAM APPLICATION |
Cougar Mountain Zoological
Park, Zoological Society of Washington |
| Name |
| Address |
Social Security
# |
|
|
|
| Emergency Contact |
Name |
Relation |
Phone |
|
| Date of last TB Test |
Date of last Tetanus Shot |
|
| Do you have: |
Current CPR? |
r |
Yes, Dated |
r |
No |
Current First Aid? |
r |
Yes, Dated |
r |
No |
|
| Do you
have continuous comprehensive, personal, medical, health, hospitalization insurance? |
r |
Yes |
r |
No |
|
| Do you
Smoke? |
r |
Yes |
r |
No |
Are you willing to take a drug test? |
r |
Yes |
r |
No |
|
| Are you
18 or over? |
r |
Yes |
r |
No |
Do you have a valid Driver’s License? |
r |
Yes |
r |
No |
|
| Have you ever been convicted of a misdemeanor or a felony? |
r |
Yes
(Detail on back) |
r |
No |
|
| What is the objective of your participation in the
Extern/Intern Program? |
| . |
| . |
| . |
| . |
| What is your required time commitment? |
| What is your required Extern/Intern Program? |
r |
Part
Time |
r |
Full Time |
r |
General
Curriculum |
r |
Elective
Curriculum |
|
| Education: describe background, present
status, objectives (Detail on back or attach résumé) |
| Describe any experience relating to
Zoological Institutions (Detail on back or attach résumé) |
| Your University Extern/Intern Program
Coordinator: Name of University |
|
| Are you interested in employment in the Zoo
field upon completion of the Extern/Intern Program? |
r |
Yes |
r |
No |
|
| Do you have any physical limitations, allergies, etc..? |
r |
Yes
(Detail on back) |
r |
No |
|
| Can you lift and routinely handle weight of 50 to 80lbs? |
r |
Yes |
r |
No (Detail
on back) |
|
| Do you have any other medical, physical or mental problems
we should be aware of? |
r |
Yes |
r |
No |
|
| If yes, please explain: |
| . |
| Do you understand and are
willing to take the risk and the consequences of contracting communicable Zoonotic |
| diseases from Zoo animals? |
r |
Yes |
r |
No |
|
| Do you fully understand that
in the course of working with wild animals of any species you may be subject to |
| serious physical injury and are you willing to subject
yourself to potential injury? |
r |
Yes |
r |
No |
|
|