FamilyWise Volunteer/Intern Interest Form

Contact Information

Please DO NOT use Autofill for entering information in this form.

Date of Birth*

Permenant address required.

Country*
Email*
Confirm Email*
Phone*

Employment

Current Employer
Occupation (Job Title)

Volunteer/Intern Position

Position(s) of Interest

Volunteer/Intern Credits

If you are not required to complete an internship or do service-learning, please select Volunteer/Mentor

Position Type*
  • Clinical Intern
  • Intern
  • Service-Learning
  • Volunteer/Mentor
Name of School
Program / Major:
# of Hours Required for Internship
Type of Hours Required

Regular Availability

When would you like to start?
Availability - Days of Week*
Availability - Time of Day*
Approximate number of hours per week

Emergency Contact Information

Contact Name*
Contact Phone*
Contact Relation*

Background Information

Have you ever been convicted, imprisoned, been on probation, parole or under supervision as a result of a conviction, or been filed for any violation of the law?

An answer "Yes" to this question does not constitue and automatic bar on volunteering.

If Yes, please give dates, details and penalties for each occurrence below.

Details

Parent/Guardian Information

If under age of 18 years, complete this section.

Parent/Guardian Consent: I hereby give permission to perform volunteer service for FamilyWise. I also give my consent to FamilyWise to take whatever emergency steps necessary to safeguard the health and welfare of my child. I understand that in the event of an emergency, you will attempt to contact me. However, if I am unable to be reached, you may contact:

Name of Parent/Guardian
Phone number

ALL APPLICANTS READ AND SIGN

As a volunteer for FamilyWise, I understsand that if I am selected for a position, falsified statements on this application shall be considered sufficient cause for relief of duty. I also understand that FamilyWise, solely at its discretion, shall determine who will serve as a volunteer and may dismiss a volunteer at any time with or without cause.

Signature of Applicant*
Additional Comments

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