Download Sample Employment Application Form

Vera French Community Mental Health Center
1441 W. Central Park Avenue
Davenport, IA 52804
STUDENT/INTERN/PRACTICUM APPLICATION
Please print or type all information except signature.
GENERAL INFORMATION:
Date: _________________________________
Name
______
Last
First
Middle
Address
Number
Home Telephone (
Street
)
City
Cell Phone (
State
Zip
)
____
E-mail address
Are you a current student? ______ Yes ______ No

What school do you attend? _________________________________________________________________________

What grade or year are you in? _______________________________________________________________________


Indicate if this is a MASTERS program
Yes
No OR BACHELORS Program
Is this internship required as part of an educational program?
Yes
No



Yes
No
o
If yes, what program is this internship for? _______________________________________________________
o
If yes, name/phone number/e-mail of
advisor:__________________________________________________________________________________
o
Number of Hours Needed __________________ Is your specialty with Children or Adults? _______________
o
List any unique skills you possess _____________________________________________________________
Do you have any family members who are clients
Yes
No
What are your plans after graduation? _________________________________________________________________
What type of activity(s) are you seeking to participate in or gain exposure to: __________________________________
________________________________________________________________________________________________
Have you ever completed an internship or volunteered at Vera French before?
Yes
No
If yes, give date(s) and describe any prior internship or volunteer with Vera French: ____________________________________
_______________________________________________________________________________________________________
Where did you hear about Vera French? _______________________________________________________________________
When are you seeking to perform your internship?

Time of day: _____________________________________________________

Day of week: _____________________________________________________

How often per week/month: _________________________________________

For how long? ___________________________________________________
If you have a disability, what accommodation would you need to do this internship? ___________________
______________________________________________________________________________________________________
What training, resources or support do you anticipate needing to do this internship? ___________________
Created April, 2011
Revised: July 2011; November 2015; November, 2016 SD Cmte
______________________________________________________________________________________________________
Please provide 3 personal, professional or academic references:
Name
Phone Number
E-Mail
Relationship
1. ____________________________________________________________________________________________________
2. ____________________________________________________________________________________________________
3. ____________________________________________________________________________________________________
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CRIMINAL RECORD HISTORY:
(Note: If under the age of 18, do not answer) Have you ever been convicted of any violation of law: felonies, misdemeanors and/or
ordinance violations other than a minor traffic violation? (Example: speeding is considered a minor violation; operating while
intoxicated is major and should be disclosed). If Yes, please explain (convictions, locations, dates)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
*********************************************************************
I certify that answers given herein are true and complete to the best of my knowledge. I understand that false statements made on
this application or incomplete information may be grounds for dismissal or may eliminate me from further consideration for
participation in an internship or practicum with Vera French Community Mental Health Center.
Signature and date are required:
Signature ____________________________________________________ Date _____________________
Student/Internship/Practicum Guidelines:
 Students participating as part of a formal academic program may not engage in any activity conducted on Vera French
CMHC properties until a written memorandum of agreement (aka: Cooperative Agency Agreement) is established, and
requirements listed in that agreement are completed.
 Students not participating as part of a formal academic program shall not participate in any activity conducted on Vera
French CMHC properties without completion of this form and until written approval is given by the Staff Development
Committee or designated representative; and if necessary, all required criminal background checks, Medicare FWA
verifications, and Child/Dependent Adult Abuse Registry checks are completed and certified as clear.
 A “Participation & Approval Form” shall be completed and submitted in advance (a minimum of one business day for
one day observations, and three business days for observations or activities lasting 2 or more days) by the appropriate
supervisor to the Staff Development Committee.
Created April, 2011
Revised: July 2011; November 2015; November, 2016 SD Cmte
WAIVERS AND DISCLOSURES
Please read each section carefully and sign where indicated.
(Note: If under the age of 18, do not answer)
NOTIFICATION AND AUTHORIZATON TO CONDUCT PERSONAL HISTORY AND BACKGROUND INVESTIGATION
I understand that I may be subject to a criminal background check and/or OIG registry verification. If a criminal background
investigation and/or OIG registry verification is needed I will be provided a separate authorization form for me to sign which shall
authorize Vera French Community Mental Health Center, or any of its affiliates, to investigate my criminal background and/or OIG
registry status to determine any and all information of concern as to my record.
Additionally, I hereby authorized Vera French Community Mental Health Center to make any investigation of my personal history,
educational background, military record, motor vehicle records, and credit history either internally or through an investigative or credit
agency or bureau of Vera French’s choice. I authorize the release of this information by the individuals and/or appropriate agencies
to either Vera French Community Mental Health Center or the investigating service. This authorization, in original or copy form, shall
be valid for this and for any future reports and updates that may be required.
If a background and/or personal history investigation is conducted, I release employers and persons named in my application from all
liability for any damages on account of his/her furnishing said information, and I understand that an acceptable report is a condition of
volunteering with Vera French Community Mental Health Center. A negative background check or unacceptable personal history
investigation can be grounds for dismissal, even if a volunteer assignment has been made available to me and I have been
participating in such activity(s).
PLEASE SIGN HERE:
Date
PRINT NAME: ________________________________________________________
Vera French Community Health Center, and its affiliates, is committed to the principle of equal opportunity and employment. The
VFCMHC does not discriminate on the basis of race, color, religion, creed, sex, gender identity or sexual orientation, national
origin or ancestry, age, mental or physical disability, marital and familial status or other characteristic protected by law in
admission to, access to, or treatment in, or employment in its programs and activities. The following person has been designated to
handle inquiries regarding the VFCMHC nondiscrimination policies: Manager, Human Resource Services, Vera French Community
Mental Health Center, 1441 W. Central Park Avenue, Davenport, IA 52804. Inquiries concerning the application of nondiscrimination
policies may be also referred to: U.S. Office for Equal Opportunity and Civil Rights Commission at www.ed.gov.
Thank you for considering Vera French Community Mental Health Center.
Submit to:
Human Resources
Vera French Community Mental Health Center
1441 W. Central Park Ave.
Davenport, IA 52804
E-mail: [email protected]
Fax 563.324.4368
************************************************************************************************************************
INTERNAL USE:
Date Received _______________________________
Affiliation Agreement in place and still effective?
Practicum Site: Outpatient
Application/Resume Received?
School-Based
YES
Pine Knoll
NO
Carol Center
YES
RHOH
OTHER: Explain
NO
Date forwarded to Program Manager ___________________________________
Created April, 2011
Revised: July 2011; November 2015; November, 2016 SD Cmte