Step 1 of 4

Volunteer/Intern Application

General Information

Name/Organization(Required)

Date(Required)

Today’s Date

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Work Phone

Cell Phone

Best Contact Number(Required)

Email Address(Required)

Enter Email Confirm Email

Date of Birth

Gender

Male

Female

Primary Language

Other Languages Spoken

Current Employer

Street Address

Street Address Address Line 2 City State ZIP Code

Current Position

Will You Be Compensated for Volunteer Hours Through Your Company?

Yes

If Yes, Will You Need Certification of Your Volunteer Hours for Your Company?

Yes

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)

Print Name of Parent/Legal Guardian

if Applicant is under 18

Signature of Parent/Legal Guardian

if Applicant is under 18

Date

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