Internship Application HomeInternship Application "*" indicates required fields Applicant's InformationName*Please include full First, Middle and Last name. First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail* Social Security Number(For background check purposes)Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderSelectFemaleMaleNon-binaryPrefer not to answerThis field is hidden when viewing the formEmergency ContactThis field is hidden when viewing the formEmergency Contact Name Emergency Contact First Name Emergency Contact Last Name This field is hidden when viewing the formEmergency Contact PhoneThis field is hidden when viewing the formRelationshipSelectCo-workerDaughterFatherFriendMotherNeighborSonSpouseSupervisorInternship InterestIntern Position Applying For:* Data & Research Intern CSFP Public Health Intern Produce for Better Health Intern Nutrition & Food Security Intern Social Work Intern Dementia Programs Intern Other/Not Listed OtherThis field is hidden when viewing the formInternship Interest Aging & Disability Resource Center Care Management Development Fiscal Human Resources Marketing Meals & More Safe at Home Why would you like to intern at CICOA?How did you hear about CICOA?SelectJob Fair or Community EventGoogle/Search EngineDirect MailEmailSocial MediaWork + Learn IndianaNews StoryPersonal ContactOtherResumePlease attach.Max. file size: 10 MB.ICARE ValuesICARE stands for Integrity, Courage, Accountability, Respect and Excellence. These values are important to everyone's work and learning experience at CICOA, and we'd like to know how you have demonstrated these.Describe a time when you felt operations with an employer or colleague didn’t rise to the level of always doing what’s right regardless of the situation. What did you do to address this?*Describe a time when you displayed courage. Specifically, what did you observe and what steps did you take in “if you see something, say something”?*Describe a specific example that demonstrates you can hold people accountable to perform, and give an example that demonstrates how you responded to being held accountable for performance.*What does respect mean to you, in your own words? Provide an example of when you felt disrespected or witnessed a colleague being disrespected and what you did to address this.*Describe a time when you went above and beyond to demonstrate an excellent experience with colleagues or customers.*Release of InformationConfidentiality and Non-Disclosure Agreement* I agree to the Confidentiality and Non-Disclosure Agreement.I understand the sensitive nature of information I may receive as a result of my Volunteer experience and agree to follow CICOA’s policy on the confidential nature of certain client information. I agree to sign a Confidentiality and Non-Disclosure Agreement.Criminal Background Check* I agree to a Criminal Background Check.We require criminal background checks for all volunteers except those participating in seasonal group projects and Safe at Home. I understand that CICOA requires criminal history and/or driving record background checks for the purpose of evaluating me for a volunteer position. I understand that a background check is a consumer report which is covered under the Fair Credit Reporting Act. The consumer report may include the following areas: verification of social security number, criminal history records, and motor vehicle records to include traffic citations and registration. I hereby authorize CICOA to obtain a Consumer Report, to verify information that I have voluntarily supplied. This authorization and consent shall be valid in original, on-line, fax or copy form. I certify that the information contained on this form is true, correct and complete to the best of my knowledge. I also understand that any misrepresentation, falsification or omission of facts herein may be grounds for disqualification or separation. If a volunteer decision which adversely affects me is made based upon information obtained through a consumer report, I understand that I have the right to request a free copy of the report. If I dispute the information, I have the right to conclusively demonstrate the inaccuracy of the information.Liability Release* I agree to the Liability Release.In consideration of the opportunity afforded me to participate in this Program, I hereby agree that I, my assignees, heirs, guardians, and legal representatives will not make a claim against CICOA Aging & In-Home Solutions, or any of its affiliated organizations, or either of their officers or directors collectively or individually, or the supplier of any materials or equipment that is used in the project, or any of the other volunteer workers, for the injury or death to me arising from my participation in the project. Without limiting the generality of the foregoing, I hereby waive and release any rights, actions, or causes of actions resulting from personal injury or death to me sustained in connection with my participation in the project.Voluntary Participation and Execution* I agree to the Voluntary Participation and Execution Agreement.I acknowledge that I have willingly agreed to serve as a volunteer for the CICOA Aging & In-Home Solutions Volunteer Program. I have read this agreement and I fully understand its contents. I am aware that this is a release of all liability and a contract between me and CICOA Aging & In-Home Solutions, and I sign it of my own free will.Photo Release I agree to the Photo Release.I certify that I am twenty-one years of age or over and hereby voluntarily and without compensation give CICOA Aging & In-Home Solutions (the organization), its successors and assigns and those acting under its permission or upon its authority, the unqualified right and permission to reproduce, publish, circulate or otherwise use my name and/or likeness of me in which I may be included in whole or in part. I waive any right to inspect and approve the finished product or copy that may be used or the use to which it may be applied. This authorization and release covers the use of said materials in any published or broadcast form and any medium of advertising or publicity.This field is hidden when viewing the formReleases Confidentiality and Non-Disclosure Criminal Background Check Liability Release Photo Release Voluntary Participation and Execution Please read the explanations below and check all boxes.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
