Alone We Can Do So Little; Together We Can Do So Much

Volunteer & Internship Application

“Alone we can do so little; together we can do so much”

Helen Keller

PERSONAL INFORMATION:

Name: ______Today’s Date: ______

LastFirstMiddle

Email: ______Preferred Phone Number: ______

Date of Birth: ______Social Security Number: ______

Address: ______

StreetCityStateZip Code

How did you hear about DIAA volunteer opportunities?

______

Please circle which kind of volunteer would you like to be? Direct Indirect

Direct volunteers will be required to take 32-hour training for interacting / helping with deaf, hard of hearing and deaf-blind domestic violence and sexual assault victims / survivors. Indirect volunteers will not interact withvictims / survivors. Both volunteers will get 3-hour training on confidentiality provided by DIAA Staff.

Please circle the area/s you are interested in volunteering:

Office SupportEvent PlanningYouth ActivitiesTechnology

Community SupportOutreach Support Legal Advocacy Support

FundraisingWeb Design

Please circle the area/s you have experiences in:

Office SupportEvent PlanningYouth ActivitiesTechnology

Community SupportOutreach Support Legal Advocacy Support

FundraisingWeb Design

EDUCATION:

School / Name / Location / Course of Study / Did you graduate? / Diploma / Degree
High School
Business / Trade/ Technical
College
Graduate

ADDITIONAL TRAININGS(Seminars, Professional Memberships, Workshops, Apprenticeships):

______

SKILLS (List other special skills – languages, machine operation, computer, licenses, certificates, etc. - relevant to the position for which you are wishing to volunteer for.): ______

______

EMPLOYMENT:

Please give accurate, complete employment record. Include full time, part time, and self-employment, volunteer, seasonal and temporary positions. Start with your present or most recent employer. Please complete if you are attaching a resume.

Employer: ______Position Title: ______

Address: ______From (mth/yr) ______to (mth/yr)______

Phone: (_____) ______

Job Duties:______

______

Reason for leaving: ______

Supervisor: ______May we contact your supervisor? Yes No

If no, please state reason: ______

Employer: ______Position Title: ______

Address: ______From (mth/yr) ______to (mth/yr)______

Phone: (_____) ______

Job Duties:______

______

Reason for leaving: ______

Supervisor: ______May we contact your supervisor? Yes No

If no, please state reason: ______

Employer: ______Position Title: ______

Address: ______From (mth/yr) ______to (mth/yr)______

Phone: (_____) ______

Job Duties:______

______

Reason for leaving: ______

Supervisor: ______May we contact your supervisor? Yes No

If no, please state reason: ______

PROFESSIONAL REFERENCES:

Please list the names, addresses, and telephone numbers for three people, not related to you.

______

______

______

______

AVAILABILITY:

Please choose your number of hours you are available each week. Please know that we are also flexible.

Full Time _____Part Time _____Days Only ______

Evenings Only ______

NOTE: ______

______

QUESTIONS:

Share briefly your understanding of domestic violence and sexual assault:

______

What are your reasons for wanting to volunteer with DIAA?

______

If your volunteer service will fulfill a class requirement, please list the class name, goal of your services and how many hours you must complete.

______

If you are volunteering to fulfill a community service requirement, please state your offense and the number of hours you must complete.

______

Have you been convicted of a felony? YESNO

If yes, please explain.

______

Have you been suspected or convicted of child abuse?YESNO

If yes, please explain.

______

DIAA reserves the right to suspend or terminate a volunteer if the person’s belief or actions are not aligned with our mission statement.

By signing I ______acknowledge my understanding of

PRINT NAME

the above statement and expectations for volunteer services.

______SIGNATURE DATE

CONFIDENTIALITY AGREEMENT:

I ______understand that the Deaf Iowans Against Abuse insists that its interns/volunteers adhere to a strict code of confidentiality. As an intern/volunteer, I understand that any stories I hear about domestic violence and sexual assault victims/survivors are confidential. I will not discuss these stories with anyone else other than DIAA staff or other interns / volunteers.

I am aware that other DIAA staff or other interns/volunteers may share personal experiences during training or during my time with DIAA. Those presenting in this training and during my time with DIAA may also give me confidential information, and I realize this information must also be kept confidential.

I am also aware that this confidentiality agreement pertains to the location of the offices. I agree to adhere to this confidentiality agreement. Further, I understand that failure to do so may result in being asked to leave training or discontinue any contact with DIAA as a volunteer advocate, and forfeit my status as a certified advocate. I have read and understand the above statement, and I will abide by it.

______SIGNATURE DATE

AUTHORIZATION FOR REFERENCE REQUESTS

I have applied with Deaf Iowans Against Abuse for an internship / volunteering service and I desire that they be fully advised of my record with former employers. I, therefore, respectfully request that you furnish the requested information concerning my internship / volunteering service with your organization, and I hereby release you from any and all liability of damages for providing the information requested.

______PRINT NAME

______SIGNATURE DATE

PRE INTERNSHIP / VOLUNTEERING SERVICE AGREEMENT

Please read these sections carefully and sign.

I declare that the statements in this application are true and falsification of any of the provided information will be the basis for refusal to sponsor as an intern / volunteer or if sponsored, for immediate termination. I agree that my internship /volunteering service is subject to the results of reference check and /or employment verifications.

I understand and agree that nothing contained in this application form or the company’s policy handbook, or in any other rules, regulations, policies, nor any practice should be interpreted as creating a contract. (Copies of the handbook and other information may be received after volunteering service begins). I further understand that if I am sponsored for any reason, both the program and I have the right to discontinue the internship / volunteering relationship at any time and without prior notice.

______PRINT NAME

______SIGNATURE DATE

Thank you for taking the time to complete this application.

Please return this application to:

ATTN: Jeremy G. Vinluan,

Volunteer & Community Outreach Coordinator

Deaf Iowans Against Abuse

1652 42nd Street NE Suite D

Cedar Rapids, IA 52402

Electronic version is acceptable. You may email your application to:

Check us out on diaaiowa.org

Like us on facebook.com/deafiowansaginstabuse

1 – Deaf Iowans Against Abuse Volunteer & Internship Application