Internship Application

Internship Application

Please complete the below and upload any requested information
Your Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Emergency Contact Information
Emergency Contact*

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.

Internship Information
What type of an internship are you seeking?*
Why are you interested in an internship with our organization?*
What specific experience would you like to gain through this internship? Please explain the type of activities or projects required for your program, including the level of mentoring or supervising required, and other relevant information to help us determine if this internship would be a good fit.*
Are you requesting that your college/university grant you credit for your internship?*

YesNo
Name of College/University
College/University Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
College/University Phone Number
Please enter a valid phone number.

Academic & Employment Information
Current (or most recent) name of College/University *
College/University Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major/Minor

Major Minor
Type of Degree
Date Received/To Be Received

MonthDayYear
Date
Total Units/Credit Completed
Relevant Courses
Please list or describe your work and volunteer experience (if applicable):

Policies & Agreements

Please read & review each section
Confidentiality Agreement
The business and internal affairs of Age Well Senior Services, Inc., (AWSS) must be kept confidential. The business and internal affairs of AWSS should not be discussed with anyone outside the organization, except when required in the normal course of business. Interns are subject to Code of Ethics, and are prohibited from disclosing any confidential information to anyone, other than designated staff. Interns are not to remove confidential/sensitive documents or computer files from Age Well’s worksite. Access to certain confidential or sensitive information and operating procedures will be limited to those interns who "need to know." Interns handling confidential information are responsible for its security.

Upon the completion of the internship, the intern agrees to return all material and documentation (in whatever form or medium) containing or pertaining to the agency’s which the intern possesses or has under his/her control to the Supervisor. All confidential information shall remain AWSS’s property at all times.
I have read & reviewed the above Confidentiality Agreement*

Yes
Hold Harmless and Release of Liability
I hereby agree to hold Age Well Senior Services, its board of directors, employees, officers, and agents harmless of any loss, damage, or injury sustained by my internship, from any cause whatsoever, arising out of or in connection with any activity as an intern.
I have read & reviewed the above Hold Harmless and Release of Liability*

Yes
Anti-Harassment Policy
Age Well Senior Services (AWSS) is committed to providing a workplace that is free from unlawful harassment. In keeping with this commitment, our company strictly prohibits all forms of unlawful harassment, including harassment based on age (40 or older), ancestry, color, religious creed (including religious dress and grooming practices), denial of family and medical care leave, disability (mental and physical), including HIV and AIDS, marital status, medical condition (cancer and genetic characteristics), genetic information, military and veteran status, national origin (including language use restrictions), race, sex (including pregnancy, child birth, breastfeeding and medical conditions related to pregnancy, child birth or breastfeeding), gender, gender identity and gender expression, sexual orientation, or any other protected status in accordance with all applicable federal, state and local laws.

AWSS prohibits unlawful harassment, including verbal, physical and visual harassment. AWSS also prohibits comments, gestures and conduct which might not violate state or federal law, but which are inappropriate in our workplace. No person in this organization is exempt from this policy.

By way of example only, racial or ethnic remarks, slurs or jokes will not be tolerated. Any other comments, gestures or conduct that disparages individuals or groups based upon any of the factors listed above will not be tolerated.

Behavior that is inappropriate in our workplace includes abusive conduct, bullying and other forms of disruptive behavior.

All employees, interns and volunteers are responsible to do their part to assure that our workplace is free from harassment.

If you believe that you have experienced unlawful harassment by any employee, supervisor, manager, participant, vendor, or other person doing business with or for AWSS, or that any such person’s comments, gestures or conduct are objectionable, you should immediately report the matter to your Supervisor or to the Human Resources Department, or if necessary, any other supervisor or manager, including the Chief Executive Officer.

In addition, if you believe that another person in our organization has experienced unlawful harassment you should immediately report the matter to your Supervisor or to the Human Resources Department, or if necessary, any other supervisor or manager, including the Chief Executive Officer.

All complaints received will be taken seriously and will be promptly investigated in a fair, timely and thorough manner. The investigation will be documented and tracked for reasonable progress and timely closure. Confidentiality will be maintained to the extent possible. Everyone concerned will be provided with due process and a reasonable conclusion will be reached based on the evidence. If AWSS determines that harassment has occurred, remedial action will be taken to resolve the problem and may include disciplinary action against the harasser, up to and including termination.

AWSS prohibits any reprisals or retaliation against any individual for reporting or making a complaint of harassment or of any otherwise objectionable comments, gestures or conduct, or for participating in an investigation of any such report or complaint.
I have read & reviewed the above Anti-Harassment Policy*

Yes
Sexual Harassment
Age Well Senior Services (AWSS) will not tolerate and prohibits unlawful sexual harassment. Unlawful sexual harassment can include unwelcome sexual or gender-based conduct that unreasonably interferes with an individual's job performance or creates an intimidating, hostile, or offensive working environment.

Common examples include:
- Verbal or written conduct such as derogatory comments, slurs, epithets, notes, messages, invitations, email or jokes.
- Visual conduct such as leering, gesturing, sexually suggestive pictures, posters, or calendars; Internet or email materials that contain sexually explicit or suggestive pictures, cartoons or pornography.
- Physical conduct such as unwelcome touching, hugging, or blocking someone's path in an inappropriate or sexual way.
- Unwanted romantic conduct such as sexual advances, invitations or attention.
Unlawful sexual harassment also includes unwelcome sexual advances or requests for sexual favors where submission to such conduct is made an explicit or implicit term or condition of employment, or where submission to or rejection of such conduct is made the basis of employment decisions affecting an individual (quid pro quo harassment).This policy applies to all employees, including supervisory and non- supervisory employees, volunteers, interns, vendors, contractors, or any other person doing business with or for AWSS.

If you believe that you have experienced unlawful harassment by any employee, supervisor, manager, participant, vendor, or other person doing business with or for AWSS, or that any such person’s comments, gestures or conduct are objectionable, you should immediately report the matter to your Supervisor or to the Human Resources Department, or if necessary, any other supervisor or manager, including the Chief Executive Officer.

All complaints received will be taken seriously and will be promptly investigated in a fair, timely and thorough manner. The investigation will be documented and tracked for reasonable progress and timely closure. Confidentiality will be maintained to the extent possible. Everyone concerned will be provided with due process and a reasonable conclusion will be reached based on the evidence. If AWSS determines that harassment has occurred, remedial action will be taken to resolve the problem and may include disciplinary action against the harasser, up to and including termination.

AWSS prohibits any reprisals or retaliation against any individual for reporting or making a complaint of harassment or of any otherwise objectionable comments, gestures or conduct, or for participating in an investigation of any such report or complaint.
I have read & reviewed the above Sexual Harassment Policy*

Yes

Personal Appearance/Dress Code Policy
Interns shall use their common sense and good judgement with regard to their dress and shall present a professional image for Age Well Senior Services (AWSS). In addition, interns should dress according to the requirements of his/her position, and avoid any clothing that could create a safety hazard. Clothing should always be neat and clean.

When in doubt as to what constitutes proper attire, the intern should consult his/her Supervisor. Department managers may issue more detailed, written guidelines. Anyone who reports to work inappropriately dressed may be counseled or asked to clock out and return to work in acceptable attire.

Interns will be required to wear closed toe shoes for certain positions (e.g. appropriate footwear with non- slip soles). Additional dress requirements for some positions may apply, please consult with your Supervisor.

The following business dress code policy will be in effect Monday through Thursday. The overall look should be professional.

ACCEPTABLE (Monday-Thursday)
- Casual dress slacks that fit properly in both size and length (no holes, tears, or fraying edges.)
- Skirts and dresses of appropriate length and style (no shorter than 4 inches above the knee.)
- Leggings with a blouse, sweater or blazer that is long enough to cover your hips.
- Blouses and shirts. Sweaters jackets, coats.
- Sleeveless dresses and blouses (straps no thinner than two inches (2”) at narrowest point.)
NOT PERMITTED
- Denim of any style or color. (Monday-Thursday)
- Sweatshirts, sweat pants, or gym style clothing.
- Blouses that expose the midriff.
- Tight or see through clothing.
- Flip flops, beach shoes (no snow boots, no Ugg style boots).
- Kerchiefs, hats, beanies or bandannas worn on the head.
- The following dress code policy will be in effect on Friday’s only.
ACCEPTABLE (Friday’s)
- Jeans many be worn provided they are in good shape (no holes, or fraying edges).
- Skirts and dresses of appropriate length and style.
- Leggings may be worn with a blouse, sweater or blazer that is long enough to cover your hips.
- T-shirts may be worn provided they are in good condition and do not have any derogatory sayings
  on them.
- Tennis shoes, Boots (no snow boots, no Ugg style boots).
I have read & reviewed the above Personal Appearance/Dress Code Policy*

Yes

Code of Ethics
1. Interns are expected to obey the law
  - As a student intern you are expected to conduct business in accordance with all applicable laws and regulations.
2. Interns are expected to promote a positive work environment
  - You are expected to promote a work place where all feel respected and appreciated. Harassment or discrimination of any kind is unacceptable. In order to achieve excellence, you must support honesty, integrity, respect, trust and responsibility at the highest levels. This includes being timely and ethical toward work schedules and attendance policies.
3. Interns must work safely to protect themselves and the agency’s employees
  - You are committed to support a drug-free, safe and healthy work place.
4. Interns must keep accurate and complete records
  - No one should rationalize or consider misrepresenting facts or falsifying records. It is illegal, will not be tolerated, and will result in disciplinary action.
5. Interns must avoid illegal and questionable gifts or favors
  - Interns should never accept gifts from clients/vendors or donors of the organization.
6. Interns must steer clear of any conflicts of interest
  - Avoid any relationship, influence, or activity that could impair your ability to make objective and fair decisions when performing your internship.
7. Interns must protect proprietary information
  - Keep proprietary documents protected and secure. They must not be disclosed to anyone without proper authorization. Respect all confidences.
8. Interns must obtain and use assets wisely
  - Proper use of company property, facilities and equipment is your responsibility. Guard against waste and abuse of property /assets. Be cost conscious and alter to opportunities to improve performance while reducing costs. The abuse of company time, materials, and the removal or borrowing of company property without permission is prohibited.
I have read & reviewed the above Code of Ethics*

Yes

Documentation - Upload
Valid CA Driver's License

Cancelof
Valid CA Driver's License Expiration Date

MonthDayYear
Date
Proof Vehicle Insurance

Cancelof
Vehicle Insurance Expiration Date

MonthDayYear
Date
Abilities Group leaders, if your company provides insurance, please note your company:
Proof Vehicle Registration

Cancelof
Vehicle Registration Expiration Date

MonthDayYear
Date

Intern Training

Please review the below documents
I have read & reviewed the above training*

Yes
I have read & reviewed the above training*

Yes
I have read & reviewed the above training*

Yes
I have read & reviewed the above training*

Yes
I have read & reviewed the above training*

Yes
I have read & reviewed the above training*

Yes

Meals on Wheels Training Video
What was the training video code word a the end of the video?
Link if video is not loading : https://galleries.vidflow.co/videos/bflkrerl

Background Check Requirement

In the safe keeping of our seniors and community, a background check is mandatory to be an Age Well Intern for those intern +18 years and over
If we do not have a recent background check online (within 12-18 months), you will be receiving a separate email from Sterling Volunteers (TheAdvocates@sterlingvolunteers.com) on behalf of Age Well Senior Services to complete the background check online. Please check your SPAM/Junk Folder in case you miss the email.

Age Well is a 501 (C) (3) nonprofit organization. The $19.00 cost of the background check is covered by Age Well. If you would like to offset any portion of this cost, we greatly appreciate your support. A contribution is not required to be an intern. This may be tax deductible, please check with your tax advisor.
Do you authorize Age Well Senior Services to complete an online Background Screening if I do not have one currently on file?*

YesNoI am a minorProvided by College/University Internship Proctor
DOB*

MonthDayYear
Date
For more information about the Sterling Volunteers background check, please use the link below:

https://www.sterlingvolunteers.com/about/faqs/

Complete Application

I certify that my answers are true and complete and to the best of my knowledge. If this application leads to an internship, I understand that false or misleading information will result in dismissal.
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Date*

MonthDayYear
Date
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	Monday	Tuesday	Wednesday	Thursday	Friday
9 AM - 11AM
12 PM - 2 PM
3 PM - 5 PM
Other

Internship Application

Emergency Contact Information

Internship Information

Academic & Employment Information

Availability & Skills

Policies & Agreements

Confidentiality Agreement

Hold Harmless and Release of Liability

Anti-Harassment Policy

Sexual Harassment

Personal Appearance/Dress Code Policy

Code of Ethics

Documentation - Upload

Intern Training

Meals on Wheels Training Video

Background Check Requirement

Complete Application