Volunteer Services Program - Unpaid

CITY OF CHICAGO DEPARTMENT OF FAMILY AND SUPPORT SERVICES,
VOLUNTEER SERVICES PROGRAM Pages 1 of 3

APPLICATION:

City of Chicago Department of Family and Support Services, Human Resources Division,
1615 W. Chicago Ave. 5th Floor Chicago, Illinois 60622 Attention: Latoya Bonds

Website:

http://www.chicago.gov/city/en/depts/dhr/provdrs/emp/svcs/internships.html

Thank you for considering DFSS as a place to donate your time and talents. We appreciate
you taking the time to fill out this application which will assist us in matching your skills and
interests with our available volunteer opportunities.

Print or Type in answers:

Date: ______________________________________________________ (Month/Day/Year)

Name: _______________________________________________________ (Last) (First) (MI)

Current Address: ____________________________________________________________

City: ___________________________ State: __________________ Zip Code: ___________

Home Phone: ________________ Work Phone: _______________ Cell Phone: __________

Best time to call: __________________________

E-Mail: ____________________________________________________________________

EMERGENCY CONTACT:

Name: ____________________________________________________________________

Relationship: _______________________________________________________________

Address: ___________________________________________________________________

City: _________________________________ State: ________________________________

Zip Code: _______________ Phone: ____________________________________________

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CITY OF CHICAGO DEPARTMENT OF FAMILY AND SUPPORT SERVICES,
VOLUNTEER SERVICES PROGRAM Pages 2 of 3

Circle the days you can volunteer:

Mon Tue Wed Thu Fri

Please list time preferences:
Morning's Afternoons

SKILLS, EXPERIENCES & INTERESTS:

How did you learn about volunteer opportunities at DFSS?

Why do you want to volunteer for DFSS and what do you want to gain from this volunteer
experience?

Have you heard about any volunteer opportunities that interest you?

Do you have any skills, talents, or interests you would like to share?

Please describe your prior volunteer experience (include organization names and dates of service),
if any.

EDUCATION:

Highest Level of Education:

EMPLOYMENT:
Current Employer, if applicable: Position/Title:

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CITY OF CHICAGO DEPARTMENT OF FAMILY AND SUPPORT SERVICES,
VOLUNTEER SERVICES PROGRAM Pages 3 of 3

Dates of Employment

(Starting/ending): __________________________________________________________________

Company/Employer: ________________________________________________________________

Address: __________________________________________________________________________

REFERENCES:

Please list two people besides relatives and employers whom you have known for at least two
years and who know you well enough to provide us with a reference Name

Name: ____________________ Phone: _____________ Relationship to you:

Name: ____________________ Phone: ______________ Relationship to you: _________________

Note:
To be considered as a volunteer, you must complete a criminal background check
(fingerprinting) with the City of Chicago.

Note:
You may be required to stand for long periods of time and lift up to 20 lbs. during volunteer
activities. LIABILITY WAIVER "The undersigned hereby understands and agrees to
personally assume any and all liability and risk of volunteering at the Department of Family
and Support Service. Further, the undersigned hereby agrees to hold harmless the City of
Chicago, its employees, and agents from any responsibility or liability for any and all personal
injuries that may occur while volunteering at the office or during off-site events." The
undersigned understands and agrees that if accepted as a volunteer, he/she would not be an
employee of the City of Chicago and would not be entitled to any compensation or benefits of
any kind.

AGREEMENT AND SIGNATURE:
By submitting this application, I affirm that the facts set forth in it are true and complete. I
understand that if I am accepted as a volunteer, any false statements, omissions, or other
misrepresentations made by me on this application may result in my immediate dismissal.

PRINT APPLICANT'S NAME APPLICANT'S SIGNATURE DATE

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