Volunteer Services Program - Unpaid at City of Chicago

CITY OF CHICAGO DEPARTMENT OF FAMILY AND SUPPORT SERVICES,VOLUNTEER SERVICES PROGRAM Pages 1 of 3APPLICATION:City of Chicago Department of Family and Support Services, Human Resources Division,1615 W. Chicago Ave. 5th Floor Chicago, Illinois 60622 Attention: Latoya BondsWebsite:http://www.chicago.gov/city/en/depts/dhr/provdrs/emp/svcs/internships.html Thank you for considering DFSS as a place to donate your time and talents. We appreciateyou taking the time to fill out this application which will assist us in matching your skills andinterests with our available volunteer opportunities.Print or Type in answers:Date: ______________________________________________________ (Month/Day/Year)Name: _______________________________________________________ (Last) (First) (MI)Current Address: ____________________________________________________________ City: ___________________________ State: __________________ Zip Code: ___________ Home Phone: ________________ Work Phone: _______________ Cell Phone: __________ Best time to call: __________________________ E-Mail: ____________________________________________________________________ EMERGENCY CONTACT:Name: ____________________________________________________________________ Relationship: _______________________________________________________________ Address: ___________________________________________________________________ City: _________________________________ State: ________________________________ Zip Code: _______________ Phone: ____________________________________________ Page 1V.L. 02/05/2016 CITY OF CHICAGO DEPARTMENT OF FAMILY AND SUPPORT SERVICES,VOLUNTEER SERVICES PROGRAM Pages 2 of 3Circle the days you can volunteer:Mon Tue Wed Thu FriPlease list time preferences:Morning's AfternoonsSKILLS, EXPERIENCES & INTERESTS:How did you learn about volunteer opportunities at DFSS? Why do you want to volunteer for DFSS and what do you want to gain from this volunteerexperience? Have you heard about any volunteer opportunities that interest you? Do you have any skills, talents, or interests you would like to share? Please describe your prior volunteer experience (include organization names and dates of service),if any. EDUCATION:Highest Level of Education:EMPLOYMENT:Current Employer, if applicable: Position/Title:Page 2V.L. 02/05/2016 CITY OF CHICAGO DEPARTMENT OF FAMILY AND SUPPORT SERVICES,VOLUNTEER SERVICES PROGRAM Pages 3 of 3Dates of Employment(Starting/ending): __________________________________________________________________ Company/Employer: ________________________________________________________________ Address: __________________________________________________________________________ REFERENCES:Please list two people besides relatives and employers whom you have known for at least twoyears and who know you well enough to provide us with a reference NameName: ____________________ Phone: _____________ Relationship to you:Name: ____________________ Phone: ______________ Relationship to you: _________________ Note:To be considered as a volunteer, you must complete a criminal background check(fingerprinting) with the City of Chicago.Note:You may be required to stand for long periods of time and lift up to 20 lbs. during volunteeractivities. LIABILITY WAIVER "The undersigned hereby understands and agrees topersonally assume any and all liability and risk of volunteering at the Department of Familyand Support Service. Further, the undersigned hereby agrees to hold harmless the City ofChicago, its employees, and agents from any responsibility or liability for any and all personalinjuries that may occur while volunteering at the office or during off-site events." Theundersigned understands and agrees that if accepted as a volunteer, he/she would not be anemployee of the City of Chicago and would not be entitled to any compensation or benefits ofany kind.AGREEMENT AND SIGNATURE:By submitting this application, I affirm that the facts set forth in it are true and complete. Iunderstand that if I am accepted as a volunteer, any false statements, omissions, or othermisrepresentations made by me on this application may result in my immediate dismissal.PRINT APPLICANT'S NAME APPLICANT'S SIGNATURE DATEPage 3V.L. 02/05/2016