INTERN APPLICATON
Submitting this application is NOT guarantee of an internship at Home Start, Inc. All information in this document is CONFIDENTIAL. ----------------------------------------------------------------------------------------This application is intended for students receiving academic credit for direct experience exceeding 15 hours / week. If your class requires VOLUNTEER hours with a nonprofite for a semester, do NOT complete this application! Email Volunteer Program Coordinator Manasi Watts directly for information at mwatts@home-start.org.
First Name
*
Preferred first name to be used
Last Name
*
Last / Sur Name
Legal name if different
Name on your government issued ID
Birthday
*
-
Month
-
Day
Year
Date
Preferred Pronouns
(e.g. He/Him; She/Her, They/Them, etc.)
CURRENT CELL Phone Number
*
Please enter a valid phone number.
CURRENT Preferred Email Address
*
Email is our PRIMARY mode of communication. Please enter the email address you check and respond to most reguarly.
Emergency Contact Name and Cell Number
*
Contact First + Last Name + Cell Number
CURRENT LOCAL ADDRESS [We promise not to add you to any mailing lists!]
*
Street Address
LOCAL Address Line 2
Street Address Line 2
City
*
City
Zip Code
*
Zip Code
Languages spoken other than English
*
Languages
How did you hear about Home Start?
*
Word of Mouth
Web Search
Home Start Staff
My School
Other
School
*
School you currently attend
Expected Graduation Date
*
-
Month
-
Day
Year
Expected date
I certify that I have read and understand the Home Start Internship decriptions on the Home Start website.
*
Yes
I certify that I am eligible to apply for a Home Start internship based on my school standing, curriculum requirements, and degree level.
*
Yes
Internship Degree Level (pick ONE)
*
High School
BASW
Other BA/ Undergrad
MSW
Other Masters
Doctoral
Other
Home Start Program (pick ONE)
*
BHS (graduate only)
CINA/VITA (HS or undergrad)
CSF (undergrad only)
DV Housing (undergrad only)
Other Housing (undergrad only)
Macro/Admin (graduate only)
Other
Expected / Desired START Date
*
-
Month
-
Day
Year
Internship Start Date
Expected / Desired END Date
*
-
Month
-
Day
Year
Internship End date
Have you already interviewed / been offered a Home Start internship?
*
Yes
No
How would you describe yourself?
*
Introvert
Extrovert
Ambivert (bit of both)
Briefly tell us why you are interested in this internship:
*
0/250
Briefly tell us what you are looking to learn from this experience:
*
0/250
Briefly tell us what, if any, experience you have working with vulnerable populations (do NOT refer us to your resume):
*
0/250
Briefly decribe your understanding of trauma informed services (do NOT refer us to your resume):
*
0/250
Please upload your CURRENT resume and a professional letter of recommendation from within the last year. Letters of recommendation must be on official letterhead and include current recommender contact information. ~ Personal (e.g. family, friends) letters of recommendation are not accepted. If you do not have a recent professional reference a recommendation from a Professor is acceptable.
*
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Photo Release / Media Policy: I hereby grant and convey to Home Start, Inc. all right, title, and interests in any and all photographs, images, video, or audio recordings of my likeness or voice made by Home Start, Inc. in connection with my providing volunteer services to Home Start, Inc. I grant permission to allow these images and/or all recordings to be put to legitimate use at the discretion of Home Start Inc. I relinquish all rights, title, or interest to any furnished products, reproductions, or facsimiles.
*
Yes
No
Release and Waiver of Liability
Volunteer understands that the scope of all Volunteer’s relationship with Home Start, Inc., during any and all projects, is limited to a volunteer position and that no compensation is expected in return for services provided by any Volunteer; that Home Start, Inc. will not provide any benefits traditionally associated with employment to any Volunteer; and that all Volunteers are responsible for their own expenses or insurance coverage in the event of personal injury or illness as a result of a Volunteer’s service to Home Start, Inc.
Assumption of Risk
Volunteer represents that, to their knowledge, Volunteer is in good health and suffers no physical impairment that would or should prevent participation in volunteer activities. Volunteer agrees to comply with all stated and customary instructions and safety precautions during participation in volunteer activities. All Volunteers understand that the services they provide to Home Start, Inc. may include activities that may be hazardous including, but not limited to risks associated with traveling to and from volunteer activities, lifting and carrying heavy objects, walking on natural uneven outdoor surfaces, and cleaning, that may result in physical or psychological injury, pain, illness, temporary or permanent disability and/or death, emotional loss, economic loss and property damage. As a Volunteer, I hereby expressly assume risk of injury or harm from these activities and Release Home Start, Inc. from all liability.
Confidentiality Policy
Home Start, Inc. is a social services agency where a high level of confidentiality is maintained at all times and in all places, even after my tenure with Home Start, Inc. has ended. All Volunteers are agents of Home Start, Inc. and are required by law to abide by the same strict confidentiality policies regarding clients and/or donors as Home Start, Inc. staff. Confidential information includes: the fact that a person is or has been a client receiving services from Home Start, Inc., any personally identifying information about any client and/or donor, such as his/her name, photograph, address, phone number, place of work or school, lifestyle, medical or mental health information, and any other information provided by or about the client and/or donor with the expectation of privacy. Volunteers are strictly prohibited from communicating confidential client and/or donor information to anyone outside of Home Start, Inc. except as required by law.
Acknowledgement [required for ALL VOLUNTEERS]: I acknowledge that I have read the above Volunteer Waiver and Release in its entirety, am signing it freely, including electronic signing, and that no other representations, statements or inducements apart from the foregoing written agreement have been made by Home Start, Inc. I further agree that the foregoing Release and Waiver of Liability, Assumption of Risk, and Confidentiality Policy are intended to be as broad and inclusive as is permitted by the laws of the State of California, and that if any portion thereof is deemed invalid, the remainder will continue in full legal force and effect.
*
Yes
Signature of Prospective Volunteer
*
This form MUST be signed to be valid. Volunteers under 18 must ALSO have a parent sign this form to be valid.
Name of Parent or Guardian (Required for Volunteers Under 18)
Parent / Guardian First and Last Name
Signature of Parent or Guardian (Required for Volunteers Under 18)
Forms of minors MUST be signed by a parent or guardian to be valid.
Home Start acknowledges that equal opportunity for all persons is a fundamental human value. Each applicant will be considered on the basis of individualability and merit without regard to race, color, age, religion, national origin, disability, sexual orientation, sex, gender identity or gender expression, medical condition, genetic information, military or veteran status, or marital status.
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