Long Term Volunteer & Intern Application

I am interested in *

Contact Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Date of Birth *

Emergency Contact

Name *

First

Last

Primary Phone *

Secondary Phone

Email *

Relationship *

Availability

Consistence *

Ongoing
Sporadic
Only between the certain dates*

* If only between certain dates, please enter timeframes here

I would like to serve up to ________ hours per ________.

Interest

If choose Other, please explain

Have you ever volunteered at DHR? *

Yes
No

Employment and Volunteer Experience

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in the comments section below. If additional entries are needed, please upload a document listing additional information.

Company #1 *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Job Title *

Summarize the type of work performed and job responsibilities *

Immediate Supervisor Name and Title *

Company #2

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Summarize the type of work performed and job responsibilities

Immediate Supervisor Name and Title

Company #3

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Summarize the type of work performed and job responsibilities

Immediate Supervisor Name and Title

Please attach a document showing any additional employment or volunteer History

Click or drag a file to this area to upload.

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may qualify you for the internship or volunteer position. Skills include any foreign languages you may speak fluently. *

References

List the name and phone number of three non relative references who are NOT related to you. If not applicable, list three school or personal references.

Reference #1 *

Phone *

Relationship *

Number of Years Known *

Reference #2 *

Phone *

Relationship *

Number of Years Known *

Reference #3 *

Phone *

Relationship *

Number of Years Known *

Have you ever been convicted of a DUI or DWI? *

Yes
No

Have you ever been convicted of assault and battery? *

Yes
No

Have you ever been convicted of rape or any other sexual offenses? *

Yes
No

Have you ever been convicted of assault with intent to commit rape? *

Yes
No

Have you ever been convicted of possession, distribution and/or trafficking of drugs? *

Yes
No

Have you ever been convicted of intent to commit any of the above crimes? *

Yes
No

Have you ever been subject to any court order involving sexual or physical abuse of a minor, Including, but not limited to, a domestic order or protection? *

Yes
No

Have you ever been convicted of kidnapping? *

Yes
No

Have you ever been convicted of theft? *

Yes
No

Have you ever been convicted of any crime, including sex-related or child-abuse related offenses? *

Yes
No

Answering “Yes” to the above question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness of the violation, rehabilitation and position applied for will be taken into account.

Today's Date *

Signature *

Please sign your full name in the box above to certify that you have read, fully understand and accept all of the terms of the foregoing.

Please list any additional information you would like for us to consider.

All applicants must consent to a background check.