application for volunteer/internships and partners

Tacoma-Pierce County Health Department www.tpchd.org Rev. 08/31/16 3629 South D Street, MS 1001, Tacoma, WA 98418 of 4 (253) 798-6414 (p) ▪ (253) 798-7627 (f)

Application for Volunteer/Internships and Partners

Last Name

First Name

Middle Initial

Former Last Name(s)

INTEREST Please answer the questions below by checking the appropriate box.

Where would you like to volunteer?

Administrative Services Division Communicable Disease/PHEPR Division Environmental Health Division Strengthening Families Division

What type of volunteer status are you looking for?

Partner General Volunteer Job Shadow Student in Training Student Internship: Total hours: Is this for academic credit? Yes No Academic Program: __________________ Is this for a professional license? Yes No Type of license:

Why do you want to volunteer? What type of volunteer work are you interested in? Provide the duration and your preferred schedule for this volunteer assignment:

PERSONAL INFORMATION

Are you age 18 or older? Yes No If no, you must be a minimum age of 14 to volunteer. Parental or Legal Guardian signature consent is required for minors. Primary Phone

Alternate Phone

Email Address

CURRENT ADDRESS Date From Date To Address

City

State

Zip Code

PRIOR ADDRESS Date From Date To Address

City

State

Zip Code


SKILLS List any skills or special training you wish to use in your volunteer placement:

Please list languages you are proficient in (other than English):

EDUCATION Number of years of education completed: High School

College

Graduate School

Trade/ Tech School

Other:

Name of Educational Institute

Degree/Certification Obtained

Date Received



Date Received



Date Received

PROFESSIONAL LICENSES HELD License Held

Expiration Date

License #

State

License Held

Expiration Date

License #

State

WORK EXPERIENCE List all current and previous paid and volunteer positions held in the last five years.

1-WORK EXPERIENCE Employment Volunteer

Start Date

End Date

Company

Position Title Held

Title

Tasks Performed

Reason for Leaving

Ok to Contact? Yes No

Supervisor

Phone

2-WORK EXPERIENCE Employment Volunteer

Start Date

End Date

Company

Position Title Held

Title

Tasks Performed

Reason for Leaving

Ok to Contact? Yes No

Supervisor

Phone


MILITARY SERVICE Time Served

Branch

Rank

Discharge Type

Discharge Date

Time Served

Branch

Rank

Discharge Type

Discharge Date

REFERENCES Please provide information for two individuals (non-relative) who can provide a personal or professional reference on your behalf. 1-REFERENCE TPCHD Site Supervisor: Reference Verified Date Completed: Initials: Last Name

First Name

Job Title

Phone

How Reference Knows You

Years Known

2-REFERENCE TPCHD Site Supervisor: Reference Verified Date Completed: Initials: Last Name

First Name

Job Title

Phone

How Reference Knows You

Years Known

I UNDERSTAND AND AGREE By signing this form, I understand and agree to the following: Submitting this application does not automatically authorize me to volunteer. I understand that I must meet the criteria set forth by Tacoma-Pierce County Health Department (TPCHD). I also understand that my acceptance into the volunteer program is contingent upon the receipt of a satisfactory background report, and completion and proof of applicable vaccinations/titres as determined by TPCHD. I further understand I am required to complete an orientation with a TPCHD Human Resources representative prior to starting my assignment. My volunteer services are given with humanitarian and charitable reasons and are donated to TPCHD without expectation of any compensation, salary, benefits, other payment or future employment. If I am participating in an internship or student in training program, I understand this is a learning environment for me without expectation of any compensation, salary, benefits, other payment or future employment. I certify that the information set forth in this application is true and complete to the best of my knowledge. I understand falsified statements on this application or failure to furnish all requested information shall be considered sufficient cause for rejection of my application or my dismissal from the volunteer program.

Applicant’s Signature Date

Parent or Legal Guardian Signature Providing Consent Date Your completed application packet should be provided in person or mailed to the program supervisor.

Do not email. Thank you for your interest.


This section is to be completed by the Site Supervisor

ASSIGNED TO

Division Supervisor

Program Phone

DURATION OF ASSIGNMENT

Start Date End Date

SCHEDULE

Days Working

Monday

Tuesday

Wednesday

Thursday

Friday

Start Time

End Time

Building Location

DESCRIPTION OF DUTIES Brief Description of Volunteer Duties (Project, tasks, events, work environment, travel, etc.)

Yes No Will this person be driving a personal vehicle or Health Department fleet vehicle during the operation of their volunteer assignment?

Yes No Has the Division Office Administrator been contacted regarding arrangements for a work space and other logistical needs for this volunteer assignment?

Site Supervisor: please submit this application form to the Confidential Assistant II - Office of Director for processing.

ASSIGNMENT

PLEASE COMPLETE THIS FORM AND RETURN IT TO HUMAN RESOURCES. TACOMA-PIERCE COUNTY HEALTH DEPARTMENT

ASSURANCE OF CONFIDENTIALITY

I, , understand:

• That all information I am exposed to regarding clients, participants, family member(s) of participants or clients, customers and/or employees or volunteers of the Tacoma-Pierce County Health Department or its partners/collaborators may be governed or protected by federal, state, and/or local regulations and, where privileged, is to be held in the strictest confidence;

• No privileged information will be discussed with family, friends, or any other unauthorized

person;

• I may release only that information that is duly authorized for release and for which I have training and authorization to release;

• Unauthorized disclosure is cause for disciplinary action, up to and including termination,

as well as possible criminal or civil sanctions.

Further, I hereby agree to:

• Release only that information that is duly authorized for release and will resist any effort or request for information that is protected by relevant federal, state, and/or local regulations;

• Not divulge, publish, or otherwise make known to unauthorized persons or the public

any information obtained in the course of my employment or participation with department activities;

• Institute or comply with appropriate procedure for safeguarding such information and

will hold discussions only in places that assure privacy and only on a need to know basis.

Date: Employee/Volunteer Signature Date: TPCHD Signature

_______________________________________________________________________________________

__________________________________________________________________________________________________________ To: The Office of Human Resources I acknowledge that Tacoma-Pierce County Health Department is dedicated to providing a healthy, comfortable and Tobacco-free environment for all persons. Our reasons for moving to a practice of hiring non-smokers are simple:

1. Economics • Employers spend an average of $753 per year more in medical costs for a smoker than for a non-smoker. Additionally, $68 billion in medical costs are spent in the United States for tobacco deaths alone.

2. Productivity

• Smokers miss an average of two more workdays per year than their non-smoking colleagues do. • Smoking accounts for a total annual value of lost productivity and disability time worth $47 billion per year in the United States.

3. Prevention & Objectives

• Our tobacco prevention campaign is one of our primary departmental objectives. It is important that we demonstrate healthy behaviors by our actions and through our policies and that we educate and market our tobacco prevention efforts to the Pierce County community. • Our former US Surgeon General, David Satcher, stated that “Tobacco use will remain the leading cause of preventable illness and death in this Nation. . . . until tobacco prevention and control efforts are commensurate with the harm caused by tobacco use.”

I understand that Tacoma-Pierce County Health Department serves the Pierce County community and that their tobacco prevention campaign is a primary objective. Furthermore, I acknowledge that as an employee or volunteer of the agency I will be expected to demonstrate healthy behaviors by my actions and by my compliance with departmental policies. Hence, I will be expected as a condition of my employment or volunteer service to be tobacco-free upon start date and to remain tobacco-free during my employment or volunteer service with Tacoma-Pierce County Health Department. I acknowledge that by demonstrating such behaviors, I will be educating and marketing tobacco prevention efforts to our Pierce County community. I acknowledge that current employees who use tobacco are ‘grandfathered’ in to the tobacco-free lifestyle and that they will be encouraged to quit using tobacco. In addition, I understand they are provided educational materials on the effects of tobacco and resources to help them quit. I understand that tobacco use will be strictly prohibited within the agency’s buildings, vehicles and other agency work areas for employees, volunteers and clients alike. Further, I acknowledge that I will do my part to educate those persons who violate the 50 feet standard from the department’s buildings where smoking is prohibited. (This standard is necessary so that secondhand smoke does not enter those areas through entrances, windows, ventilation systems or other means.) My signature below acknowledges that upon start date, I will be expected as a condition of my employment or volunteer service to be tobacco-free 24 hours per day and to remain tobacco-free during my employment or volunteer service with the Tacoma-Pierce County Health Department. _______________________________________________________________ ______________________________ Signature of Applicant Date __________________________________________________________ Print First and Last Name of Applicant

Tacoma-Pierce County Health Department tpchd.org Page 1 of 1

Applicants

Affidavit of Non-Tobacco Use

for Employment/Volunteer Service

Human Resources/Risk Management 3629 South D Street, MS 010 Tacoma, WA 98418-6813 253 798-6486 Fax: 253 798-6296 TDD: 253 798-6050

The Tacoma-Pierce County Health Department conducts background investigations on all employees and volunteers. Please attach a copy of your driver’s license and complete the Request for Criminal History Information form and questionnaire on the following pages.

ATTACH COPY

OF

DRIVER’S LICENSE HERE

application for volunteer/internships and partners

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