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City of Rochester

Rochester, NY Police Department - Volunteer Student Intern Application

A record check, which may take up to four weeks, is completed on all volunteer and intern applicants.
        
Position Applying For:  

* Full Name
(First, M.I., Last):

 
Maiden Name:  
DOB  
Sex:
       
* Address:  
* City:  
* State:  
* Zip Code:  
* Country:  
How long at this address:  
Previous Addess:  
Business Phone:  
Home Phone:  
Pager or Cell Phone:  
Email Address:  
Emergency Contact Name:  
Emergency Contact Relationship:  
Emergency Contact Phone #:  
Type of transportation you will use:  
Have you ever been convicted of a crime?
       
If yes, please explain:  
Education Background   
School Attended(ing):  
Major:  
Minor:  
Date diploma received or expected:  
Military Service   
Branch:  
Rank:  
Time Served:  
Date Discharged:  
Employment History   
Employer:  
Occupation:  
How Long Employed:  
Business Address:  
Previous Employment (please include business name, address, supervisor, and dates):   
Volunteer Background (please include names of organizations and dates of service):    
Skills (clerical, specific computer applications, work with youth, verbal and writtten communication, etc): 

    

Interest and Expectations (briefly state why you would like to volunteer/intern with the RPD and what you hope to gain from the experience): 

                                                                                                                                 

 

References:  NOTE: Two should be work or school related.  None should be relatives. Include name, address, phone #, and relationship. 
Reference #1   
Reference #2  
Reference #3  
Special Limitations and Conditions:   
Availability
(list times):
 
 
Monday  
Tuesday  
Wednesday  
Thursday  
Friday  
Saturday  
Sunday  
Agreement: 

*I certify that the above information is correct to the best of my knowledge.
*I authorize the City of Rochester to contact schools/colleges, former employers, references cited in this application in order to verify educational credentials, work/volunteer record, and personal character. 
*I understand that a criminal background check will be performed on all student intern and volunteer applicants.
*I understand that I may be terminated if the department becomes aware of criminal history while I am volunteering/interning.
*I understand the commitment involved and acknowledge that my services are offered at my own risk.
*I agree to adhere to the Volunteer/Student Intern policies and carry out my duties as a volunteer/student intern effectively.
*I understand that my participation in this program does not make me an employee of the City of Rochester and I release the City of Rochester, its officers, agents, employees, and any third party organization from any and all liability for any claims of injury or damage of any kind whatsoever, as a result of my participation as a volunteer/student intern.
*I understand that I am not entitled to any benefits of employment including worker's compensation.
*I will maintain confidentiality of police information.
*I will not represent myself as an employee of the Rochester Police Department.

 

Consent:  
Date:  Monday, April 14, 2014 Select a Date Delete the Date 
Youth Volunteers And, if the applicant is under 16 years of age, I understand the above terms and give permission for my child to volunteer with the Rochester Police Department. 
Parent or Guardian Consent:  
Date:  Monday, April 14, 2014 Select a Date Delete the Date 
Recommendation:  The Rochester Police Department recommends that volunteers be current on their Tetanus vaccination.


        

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