* First Name Middle Name * Last Name
* Phone (H) * Phone (W) * Phone (C)
* Street
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Emergency Contact Phone
Relationship
Email

Do you have experience working with or around individuals with mental or behavioral disabilities? Explain.

What would you like to gain by becoming a student/volunteer with HCI?

What have you enjoyed most about your previous work?

Have you ever been convicted for anything other than a minor traffic violation? If Yes, explain.

When is placement desired?

If requesting a student internship, how many total hours do you need? hours per week?

If requesting a student internship, how long of a placement do you need?

What is your preferred location to do the placement?

Availability: At what times are you available to work in a student/volunteer placement?

Education

References: List names, addresses and phone numbers of two references: (Professionals or Personal, i.e., previous supervisor, university professor, co-worker)

Name
Address
Phone

Name
Address
Phone

Read carefully, this is a release.

The student understands that Hamilton Center, Inc. does not warrant or guarantee any particular or specific results from the Student/Volunteer Placement Program. Also, by his/her participation in the program, hereby releases on his/her own behalf, or on behalf of his/her ward, Hamilton Center, Inc., its agents, servants and employees of and from any liability in conjunction with the Student/Volunteer Placement Program. The student/volunteer understands a Criminal Background Check, and also a Driver Background Check when appropriate, will be made.

By checking this box I agree to the above Applicant Certification and Agreement. This agreement serves as my electronic signature

Background Authorization Release Form

     I hereby authorize Hamilton Center, Inc. to conduct a Child Protective Services and Indiana Department of Child Services criminal fingerprinting background check at the time of hire and every four years (or at contract renewal when applicable) for any employee that has direct contact on a regular and continuing basis with DCS and IVB clients. A qualified confirmation must be received to continue employment.

     I hereby authorize Hamilton Center, their Consumer Reporting Agency (CRA), and their designated agents and representatives to conduct a review of my background causing a consumer report and/or an investigative consumer report to be generated for employment purposes and for future preparation of a consumer report or investigative consumer report for purposes of retention, promotion or reassignment unless revoked in writing. I understand that the scope of the consumer report and/or investigative consumer report may include, but is not limited to, the following areas: verification of social security number, current and previous residences, employment history including all personnel files, education history including transcripts, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state, county, city jurisdictions, motor vehicle records to include traffic citations and registration, any other public records, or information relative to my character, general reputation, personal characteristics or mode of living, if applicable. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, the Consumer Reporting Agency (CRA) or its' agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. This authorization also releases from liability to extent permitted by law or responsibility all persons, companies, or corporations supplying information regarding my background to Hamilton Center, Inc. providing they observe certain conditions of good faith and reasonableness in reporting their observations and knowledge of my clinical ability, ethical character, ability to work cooperatively with others, and other information relevant to consideration of my qualifications for employment. If an investigative consumer report is conducted I understand that I have the right to request additional information about the nature of the report and a copy of the report by calling the Consumer Reporting Agency (CRA).

     California, Minnesota & Oklahoma Applicants Only: Please initial here to have a copy of your consumer report sent directly to you. Minnesota and Oklahoma applicants will receive a copy directly from the Consumer Reporting Agency (CRA).

     California Applicants: Under Section 1786.22 of the California Civil Code, you have the right to request from the Consumer Reporting Agency (CRA), upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you, which the Consumer Reporting Agency (CRA) has previously furnished within the two-year period preceding your request. You may view the file maintained on you by the Consumer Reporting Agency (CRA) during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a summary of your report via telephone.

     Maine Applicants: Under Chapter 210 Section 1314 of Maine Revised Statutes, you have the right, upon request, to be informed within 5 business days of such request of whether or not an investigative consumer report was requested. If such report was obtained, you may contact the the Consumer Reporting Agency (CRA) and request a copy.

     New York Applicants: Under Article 25 Section 380-c (b) (2) of the New York General Business Law, you have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses. Please initial here to acknowledge receipt of Article 23-A of the New York Correction Law.

*   By checking this box I agree to the above Background Authorization and Release Form. This agreement serves as my electronic signature.