Volunteer/Intern Application Application to Become a Volunteer or Intern Step 1 of 4 25% Volunteer/Intern ApplicationGeneral InformationName/Organization(Required) Date(Required)Today’s DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone(Required)Work PhoneCell PhoneBest Contact Number(Required)Email Address(Required) Enter Email Confirm Email Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Primary Language Other Languages Spoken Current Employer Street Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Current Position Will You Be Compensated for Volunteer Hours Through Your Company? Yes No If Yes, Will You Need Certification of Your Volunteer Hours for Your Company? Yes No I Am Interested in Being a Volunteer Intern If You are Interested in Intern Opportunities:School Current Year in School Professor/Instructor Hours NeededInternship Goal/Assignment/TaskIf You are Inquiring About Volunteer Opportunities:Are You Inquiring for Yourself Individually or a Group? Self Group Group Name Quantity in GroupAreas of Service Interest(s) (Select All That Apply): Girls Shelter Boys Shelter Become a Mentor Select AllSpecial Events Volunteer: Spring Derby Fall Fashion Show Outside Donation Drive Select AllList of Members in Your GroupNote: This is required before entering the Shelter.NameAddress (including City, State, and Zip)Contact Number Add RemoveSpecial Skills/ServicesAny Other Information You Would Like to Share: What is the Best Time of Day to Contact You About Your Application? What is the Best Method to Contact You About Your Application? Have You Ever Volunteered for Seton Youth Shelters Before? Yes No Prior Volunteer Service:Seton Youth Shelters is proud to be a Presidential Volunteer Service Award – Certifying Organization. All Seton volunteers (uncompensated and non-court ordered) and interns are eligible for earning volunteer credit hours toward annual award recognition from Seton Youth Shelters.If you are interested in earning PVSA award recognition for yourself or your group, please indicate here: YES: Please track my/our service for possible annual PVSA recognition! NO: I/We do not wish to be award recognized for PVSA volunteer service at this time. I understand that if selected for some areas of volunteer service / Internship with Seton Youth Shelters, that I may be required to have a criminal and DMV background check completed (at Seton’s Expense) and may be subject to additional precautionary safety / eligibility checks or asked to provide additional information, prior to acceptance as a volunteer/ mentor/ intern, etc.; in the best interest(s) of the children we serve.Please Insert Initials Here:(Required) I also understand that any volunteer/Intern/Court Ordered activity I choose to be involved in with Seton Youth Shelters may present some risk(s) of accident or injury and that I assume full responsibility for my safety and well-being while completing volunteer / internship or court ordered activities and maintain that I am physically capable of completing such actions.Please Insert Initials Here:(Required) I, the undersigned, understand and agree that in the course of my services with Seton Youth Shelters, any medical or personal information learned by me about any person who is a resident or employee of Seton Youth Shelters, is privileged information and is subject to all State and Federal laws. These laws protect the rights of clients who are housed in, serviced as part of Street Outreach, employed with or counseled at group home facilities. I understand any information learned by me about any resident may not be discussed with anyone except authorized personnel of Seton Youth Shelters, unless otherwise approved by an authorized staff member. I understand that a breach of a resident or client’s confidentiality may result in immediate dismissal and that I could be subject to any applicable State and/or Federal regulations and laws: which include fines and/or imprisonment. I state that I have read (and understand) this agreement. I further understand that this application / agreement will be retained in the personnel records file at Seton Youth Shelters main office.Print Name of Applicant(Required)Signature of Applicant(Required)Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Print Name of Parent/Legal Guardianif Applicant is under 18Signature of Parent/Legal Guardianif Applicant is under 18DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHAEmailThis field is for validation purposes and should be left unchanged.