Victim Services Intern Program Application

VICTIM SERVICES INTERN PROGRAM APPLICATION

Applicant’s name:______DOB:______

Residence address:______

Mailing address:______

City, State & Zip:______

PHONE NUMBERS:

HOME:______CELL:______

OFFICE/OTHER:______EMAIL:______

Are you fluent in a language other than English?______What?______

read?______write?______speak?______

Do you identify with a specific culture?______YES ______ NO

If yes, which culture?______

How do you self-identify,racially?______

Are you an individual with a disability?______If yes, state the nature ofyour disability if you feel comfortable doing so. ? ____________

In what college, university, or alternative curriculum are you enrolled, and what is your status/standing:______

What is your major:______GPA:______

Are you declaring a minor?______, If yes, in what?______

Are you an undergrad?______Grad?______Doctorate?______

Number of credit hours this semester?______Date of graduation? ______

Academic Advisor’s name:______

PHONE:______EXT:______EMAIL:______

TELL US ABOUT YOURSELF

Why are you seeking an internship with a victim services focus?

______

List, in order of preference, the internship desired and why:

A.______

B.______

C.______

Do you have any experience working with crime victims? If so, where, and what was yourperception of that experience?______

______

Have you done volunteer work? If so, where?______

How do you manage your stress, and what do you do to limit stress?______

______

Do you have a self-care plan (how do you take care of yourself?______

______

List two of your favorite things to do:______

______

Do you work best alone, or in a team?______

Are you able to give a 9-12 month commitment to COVA and your host agency?______

***Please attach a sample of your writing addressing your expectations of the Intern Program and what you would like to gain most from your internship.

I have answered all of the questions truthfully.

Signature:______Date:

REFERENCES AND EMERGENCY NOTIFICATION

IN CASE OF AN EMERGENCY, WHO SHALL WE CONTACT?

Name:______Relationship:______

PHONE(S):______

Address:______

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Please list three references, oneprofessional, one academic, and another not related to you:

Name:______

Title:______Phone:______

Address:______

Professional relationship:______

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Name:______

Title:______Phone:______

Academic/Campus address:______

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Name:______

Address:______

How long have you known this person?______Phone:______

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COVA Victim Services Intern Program

AGREEMENT

PURPOSE & OBJECTIVES

The purpose of the COVA Victim Services Intern Program is to provide a paid practicum in the field of victim services to students of under-represented populations. The objective focus is on cultivating career opportunities, full time employment and increasing sensitivity and awareness in cultural and environmental issues within both the system and non-system sectors.

SUPERVISION AND SUPPORT:

The host agency and the COVA VSI Program has a commitment to the training and experience for the intern within victim services by providing 30-50% direct service contact. A primary supervisor is assigned to the student-intern to provide specific job-related supervision at the host agency site. A mentor from the COVA VSI Program Advisory Board will be available to the student-intern on an as-needed basis, for the purpose of networking, support and guidance. The COVA VSI Program coordinator is available at all times to the student-intern for mentoring, networking, placement opportunities, guidance and other related support.

JOB DESCRIPTIONS

A basic job description from the host agency, in which the intern is placed, will be provided to the intern prior to or on his/her first day on the job. The job description is subject to change in order to provide a continuous challenge for the intern, and to accommodate the academic schedule of the intern. A copy of the job description must be sent to the COVA VSI Program coordinator.

EVALUATION & FEEDBACK

Initially, in the first ninety days there will be an evaluation of the compatibility between intern and the host agency. Then every sixth months the student-intern and the host agency will have the opportunity to evaluate each other. The evaluation will provide a foundation for feedback, and goal setting, which is essential for progress and growth within the victim services field, and to accomplish the objectives of the COVA VSI Program.

Intern:______Date:______

COVA VSI Program Coordinator: ______Date: ______

DoraLee Larson

VICTIM SERVICES INTERN PROGRAM

AUTHORIZATION TO RELEASE INFORMATION

Dated this ______day of ______, 20__

I, ______hereby authorize the COVA Intern Program coordinator to contact the references I have provided.

I, ______hereby authorize the COVA Intern Program coordinator to conduct a criminal history and background investigation.

I, ______understand the information collected may be sensitive, confidential, and privileged and that this information will be used only as an evaluation tool to determine my suitability and eligibility with the COVA Intern program.

I, ______certify that my statements in this application are complete and correct and I have answered all the questions to the best of my knowledge.

______

Applicant’s signature

______

Printed name

______

Date of birth Social Security Number

CRIMINAL HISTORY/BACKGROUND CHECKINFORMATION:

PLEASE PRINT

FULL NAME:______

DATE OF BIRTH:______SSN#:______

PLACE OF BIRTH, CITY, COUNTY & STATE:______

HAVE YOU EVER USED OR BEEN KNOWN BY ANOTHER NAME?______YES ______NO

IF YES, PLEASE LIST THE NAMES:______

DO YOU USE A NICKNAME, PLEASE LIST:______

DRIVER’S LIC./STATE ID#______STATE:______EXP. DATE:______

HAVE YOU EVER HAD YOUR DRIVING PRIVILEGES REVOKED?_____SUSPENDED?______

RESTRICTED?______OR DENIED?______.

DO YOU HAVE DEPENDABLE TRANSPORTATION? ______

IF YOU OWN AND/OR DRIVE A VEHICLE DO YOU HAVE THE APPROPRIATE AUTO INSURANCE PURSUANT TO COLORADO STATE LAW?______

MALE:______FEMALE:______

ARE YOU CURRENTLY EMPLOYED?______IF SO, WHERE?:______

HAVE YOU EVER BEEN CHARGED OR CONVICTED OF A FELONY? ____YES_____NO

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE, PLEASE EXPLAIN:______

______

IS THERE ANYTHING ELSE YOU WOULD LIKE TO ADD?______

I understand and consent to a background check, and the sharing of information with a prospective host agency.

Signature:______date:______

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VSIP HOST AGENCY LIST

1st Judicial District (Jefferson, Gilpin Counties)

Family Tree – (Seasonal)MADD

Lakewood Police Department, Victim Assistance Unit

Ralston House (also in the 17th JD)

2ND Judicial District (Denver County)

African Community Center SafeHouse Denver

**Blue Bench (fka Rape Assistance & Awareness Program) Servicios de la Raza

Denver District Attorney’s Office

Denver City Attorney’s Office, Domestic Violence Unit

Domestic Violence Initiative for Women with Disabilities

Phoenix Center at Auraria

**Rocky Mt. Children’s Law Center

**Rocky Mt. Victim’s Law Center

17th Judicial District (Adams)

17th Judicial District Attorney’s OfficeWestminster Police Department

ACCESS Housing Thornton/ Northglenn Police Dep’t

Brighton Police Department

Broomfield Police Department

Ralston House (also in the 1st JD)

18th Judicial District (Arapahoe, Douglas, Elbert, Lincoln)

18th Judicial District Attorney’s Office (2 locations) Littleton Police Department

Arapahoe County Sheriff Office Project Safeguard Project Safeguard

Aurora Police Department, Victim Services Unit

Glendale Police Department, Victim Services Unit

Gateway Battered Women’s Services

20th Judicial District (Boulder)

**Blue Sky Bridge, BoulderSafe Shelter of St. Vrain

Boulder County Sheriff Office Victim Assistance Longmont Police Department

MESA SPAN

Multi Jurisdictional

Address Confidentiality Program

Northern Judicial Districts (Larimer & Weld County)

8th Judicial District Attorney’s Office 19th Judicial District Attorney’s Office

Alternatives to Violence Larimer County Sherriff’s Department

SAVA (Greeley & Ft. Collins)Crossroads Safehouse

** These agencies prefer graduate students or accept both undergrad and graduate students.

You may indicate which agencies you have an interest for on your application. The VSIP asks you to reframe from contacting these agencies for an internship prior to your acceptance into the COVA Intern Program. Be aware that some of these host agencies may currently have a maximum number of interns, or temporarily may not be taking interns.

You will be given recommendations of agencies once accepted into the program.