Alamance County Health Dept Student/Intern/Volunteer Application

Alamance County Health Dept Student/Intern/Volunteer Application
Full Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Person to be notified in case of an Emergency:
Contact Full Name
Contact Relationship
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Home Phone
Contact Cell Phone
Contact Other Phone
Contact Age

Under 18Over 18
Please check the category that applies to you

Student: Someone who is required to perform a given number of service hours in order to meet a school requirement.Intern: Someone who earns course credit for on-site work experience with the Health Department while attending a school of higher education.Volunteer: Someone who performs hours of service for the Health Department without promise, expectation, or receipt of compensation for services rendered.
In which Health Department Program/Area would you prefer to work? *

Clinical ServicesHealth Education and Promotion / Public InformationEnvironmental HealthDentalAdministrationWIC / Nutrition ServicesClerical / FinanceNot sure / No preference / Other
*Please note all requests for placement as a student, volunteer, or intern are based upon the needs of the agency and are not guaranteed.
Time Commitment and Availability:

Availability (Please check the days and times you are available)

	Sunday*	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday*
Morning
Afternoon
Evening

*Please note that Saturday and Sunday opportunities are very infrequent. The Health Department’s normal hours of operation are Monday through Friday, from 8:00 A.M. until 5:00 P.M.
What hours are you available? (Be specific)
Total Hours needed if you have a requirement
Beginning Date

MonthDayYear
Date
End Date

MonthDayYear
Date
If you require special accommodations per the Americans with Disabilities Act, please indicate here.

YesNo
If yes, what accommodations will you need?
How did you hear about our organization?
Have you ever been convicted of a criminal offense other than a minor traffic offense?

YesNo
If yes, please explain
References: (Non-relative; known for at least one year)
Reference 1 Full Name
Reference 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 1 Home Phone
Reference 1 Cell Phone
Reference 1 Other Phone
Reference 2 Full Name
Reference 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2 Home Phone
Reference 2 Cell Phone
Reference 2 Other Phone
Do you have a valid Driver’s License?

YesNo
If so, list Number
State of Issuance

Education

	Name and Location	Major	Degree Obtained
High School
College
Graduate School
Other

High School Diploma Received?

YesNo
GED Received?

N/AYesNo

Volunteer and Paid Experience

	Employer	Position	Duties	Dates	Reason for Leaving
Employer 1
Employer 2
Employer 3

Applicable Licenses or Certificates

	Type	Number	Date Issued	Expiration Date
License/Certificate 1
License/Certificate 2
License/Certificate 3

Languages: Indicate language other than English and check the skill that applies to you

	Language	Speaking Ability	Reading Ability	Writing Ability
Language 1
Language 2
Language 3

Please describe your experience, work or otherwise, which you feel may be helpful in the type of position in which you are interested.
What skills do you hope to gain or improve on during your experience?
How do you think that the Alamance County Health Department would contribute to your understanding of Public Health?
Explain any special skills or interests that you have that could contribute to your experience.
Why do you want to volunteer at this type of organization?
What are your goals or objectives in terms of professional or personal development and what role does the Alamance County Health Department play?
Certification:
I certify the information given in this application is complete and correct. I further understand that discovering information to the contrary may be cause for re-determination of my volunteer, student, or internship assignments with the agency.

I certify that I am covered by an independent insurance carrier and that Alamance County will not be held responsible for any injuries that I may incur as a result of my volunteer, student, or internship services for the County.
Date

MonthDayYear
Date
Signature

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If Volunteer is under 18 years of age:
I give permission for my child/ward to be a volunteer at this agency. I certify that my child/ward is covered by an independent insurance carrier and that Alamance County will not be held liable for any injuries that my child/ward may incur as a result of these volunteer, student, or internship services for the County.
Date

MonthDayYear
Date
Parent/Guardian Signature

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STUDENT/INTERN CONSENT FORM
HOLD HARMLESS/RELEASE AGREEMENT

I understand and acknowledge that there may be a risk inherent in work associated with Alamance County Government, by agreeing to serve, the intern, in conjunction with the Educational Institution, hereby assumes all risks which may arise from providing these services. Interns, by agreeing to serve as such and in return for the provision of said opportunity, will indemnify and hold harmless the County of Alamance from any and all claims for liability, loss, injury, damages, costs or attorney's fees brought against Alamance County or any of its agents, employees, or commissioners arising out of any personal injury, wrongful death, or other damage sustained by a client or agent of the County due to services provided by the Intern. Any professional liability insurance under which said intern would be covered should be carried by the intern or in conjunction with the educational institution as required by their intern’s placement with Alamance County.
Date

MonthDayYear
Date
Student/Intern Signature

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CONSENT TO SEEK EMERGENCY MEDICAL CARE

This is to authorize the department to seek emergency medical care if, in the judgment of the staff it is needed, for a medical emergency. It is understood and agreed that the said staff, the department/program, and Alamance County will be held harmless for any and all results of the staff’s efforts to obtain emergency medical treatment including any accident or injury while being transported.
Date

MonthDayYear
Date
Student/Intern Signature

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Witness Signature

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Name of local physician
Phone
Emergency contact person (local)
Contact Phone
CONSENT TO BE TRANSPORTED

It is understood and agreed that the said staff, the department/program and Alamance County will be held harmless in case of accident or injury to the student or intern while participating in program activities and while being transported to and from activities
Date

MonthDayYear
Date
Student/Intern Signature

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Witness Signature

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If you are volunteering/interning as a part of a class or other requirement, please provide a brief description of the requirements.
If you have any questions on this form, please contact

Jennifer Turner
Human Resources Specialist
Alamance County Health Department
319 N. Graham-Hopedale Rd. STE B
Burlington, NC 27217
(336) 513-5512
jennifer.turner@alamancecountync.gov
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Alamance County Health Dept Student/Intern/Volunteer Application

Time Commitment and Availability:

STUDENT/INTERN CONSENT FORM