The Saville Center for Child Advocacy

Date of Application*

Date

Email address*

example@example.com

Name: Last, First, Middle*

Date of Birth*

Date

Address*

Address

Street Address Line 2

CityState

Zip

Phone Number*

Please enter a valid phone number.

Social Security Number (for OSBI background check):*

Upload your resume here:*

Are you volunterring for class credit?*

YesNoOther

Hours required*

Education Status *

Major/Area of Study*

Expected Graduation Date*

Date

College/University*

Please indicate your internship requirements:

Hours per semester*

Hours per week*

Begin Date*

End Date*

Are you available a minimum of 10 hours per week?*

Please fill out your hours of availability for the semester that you are seeking an internship:

Monday*

Ex. 9am-5pm

Tuesday*

Ex. 9am-5pm

Wednesday*

Ex. 9am-5pm

Thursday*

Ex. 9am-5pm

Friday*

Ex. 9am-5pm

Please list any foreign languages you speak.*

Because of the sensitive nature of our work with at The Saville Center, we strive to place interns in the most appropriate position possible to meet the needs of the children and families we serve.

How did you hear about The Saville Center?*

Throughout your employment history experiences or education have you had any exposure to issues of child abuse, neglect, or domestic violence? Describe the situation and how you addressed it. *

Briefly describe why you would like to intern at The Saville Center.*

What do you know about The Saville Center? What do you expect to contribute?*

What are your career goals? Where do you want to be in 5-10 years? How do you see this internship complimenting those goals? stion*

Describe a particularly stressful situation from your work or volunteer positions and how you handled it. *

How do you manage your schedule between work, school, and activities?*

If you encounter something in a job situation or volunteer position that you do not understand, how do you handle that? *

Please list any extra-curricular activites.*

Please list any special skills hobbies or interests you have that might be helpful in your work at The Saville Center.*

What would you like to tell us about yourself that is not reflected on your resume?*

Employment

If currently employed, please complete:

Title

Company

Address

Street Address Line 2

CityState

Zip

Supervisor

Phone

May we contact your employer for a reference?

Volunteer Experience

Please list any volunteer experience, include the agency, how long, and your responsibilities.

Personal References (non family)

Name*

Phone*

Relationship*

How long have you known this person?*

Name*

Phone*

Relationship*

How long have you known this person*

Emergency Notification

In case of an emergency while at The Saville Center, please notify:

Name

Relationship

Phone number

Address

Street Address Line 2

CityState

Zip

Applicants Signature

Date

Upon receipt of your application, an interview with the Volunteer Coordinator will be set to discuss the internship. Please allow 4 weeks to process your application and background check.

FELONY AND MISDEMEANOR CONVICTION INFORMATION

The CARE Center screens prospective employees, interns and volunteers to evaluate whether an applicant poses a risk of harm to the children, youth, and families it serves. Information obtained does not automatically bar employment or volunteer opportunities. Relevant circumstances are appraised. This disclosure is to be completed by applicants prior to further consideration. Any falsification, misrepresentation, or incompleteness in this disclosure is sole and adequate grounds for rejection or termination. This agency works closely with federal, state, and local law enforcement agencies to verify all information to the maximum extent permitted by law.

I have have not * been convicted of a felony or a misdemeanor. If your answer is affirmative, give details, including date, place, nature of conviction, and disposition.

I am am not blank*currently under indictment or charged in an official criminal complaint accepted by a district or county attorney with a felony or misdemeanor. If your answer is affirmative, please give details, including the type of charges.

I have have not * ever been prohibited from serving in any capacity as an employee or volunteer with any organization or agency working with children. If your answer is affirmative, please give details, including the date and name of the organization and address.

I have have not * ever been reassigned, removed or asked to leave any position involving contact with children. If your answer is affirmative, please give details, including the date, name of organization and address.

The Saville Center does not accept applicants if they have been convicted, have prior charges, or have charges pending for a felony or misdemeanor involving a sex offense, violent act, child abuse or neglect, or related acts that would pose risks to children or to the Center's ability to provide services.

I have read this form in its entirety and understand that the information may be verified by The Saville Center, and that the inclusion and/or admission of any false information or omission of any requested information is cause for my immediate dismissal from internship and/or volunteer placement at The Saville Center. I agree to inform The Saville Center if this information changes any time during my participation as an intern and/or volunteer at The Saville Center.

Signature of Intern*

Date*

Date

PLEDGE OF CONFIDENTIALITY

Some of the work you may do if you become an intern and/or volunteer at The Saville Center will give you access to personal information about children and their families, who may be clients, volunteers or employees of the Center.

Any information observed in connection with volunteering at The Saville Center is considered strictly confidential and it may not be disclosed except as permitted or required by law and by The Saville Center policies and procedures. Confidential information includes client information that is disclosed on paperwork, interviews and follow-up meeting, client reports or records generated by The Saville Center and those sent by other agencies to The Saville Center, medical/psychosocial information and other personal information about clients, his/her seeking services of the Center, what transpired at any meeting with the client and/or any information gathered while working with the client or with the client's family as well as any personal information disclosed to you in your intern and/or volunteer capacity at The Saville Center.

VOLUNTEER PLEDGE OF CONFIDENTIALITY

I promise that I shall hold in confidence all pertinent information relating to the individual cases and clients at The Saville Center. I will not violate the confidential relationship between The Saville Center, its volunteers, participating and related agencies, courts and any and all parties interviewed or present at the Center. I will not remove any written or taped information or records from the offices of The Saville Center without the expressed permission from the Executive Director or designated professional staff.

I agree to return all information that I have gathered, together with any printed matter or notation relevant to any and all cases and/or clients to which I have been assigned, at the request of the Executive Director or any designated member of the professional staff.

I accept full responsibility for maintaining the confidential and private nature of all records and information. I understand that I am personally responsible and liable for any violation of this agreement. Your confidentiality obligation shall continue indefinitely. Failure to comply with this confidentiality agreement could result in immediate termination of your position.

INTERNSHIP/VOLUNTEER STATEMENT

I hereby acknowledge and understand that with the completion of this application, I give my permission to The Saville Center and to its authorized agents to access information with regard to any criminal history, employment history and other information that may be appropriate to my qualification to serve in The Saville Center Intern Program.

I further understand that The Saville Center has the right to review this application and subsequent information, to unconditionally accept or reject my application for intern/volunteer service, and to terminate my intern/volunteer placement at any time and that upon termination, I will return any and all properties issued to me by The Saville Center.

I agree that upon placement I will perform my intern/volunteer responsibilities without compensation and that in performing those responsibilities, I am not acting as an employee or official representative of The Saville Center.

As an intern, I understand that after successfully completing orientation and training sessions, personal time of placement, and will provide a minimum of 10 hours per week service for the entire duration of the semester. If unforeseen circumstances should prevent me from fulfilling this obligation, I will submit my written resignation to the Volunteer Coordinator with as much advance notice as circumstances permit.

I understand my conduct as an intern and/or volunteer of The Saville Center, whether interning directly at The Center or in the community at large will be decent, moral, and above reproach.

Signature of Intern*

Date*

Date