Application for Internship/Practicum Concho Valley CSCD Internship Application Last Name* First Name* Middle Initial* Telephone* Social Security Number* Texas DL#: Email* Enter Email Confirm Email Address* Street Address City ZIP Code Seeking this Internship for:* Criminal Justice Counseling/Treatment Name of college in which you are currently enrolled:* Current Academic Standing* Junior Senior Major Minor Total Number of Internship hours you are requesting.*Please enter a number from 1 to 999.Hours Per Week*Please enter a number from 1 to 40.List days of week and times you will be available to work.*ex: 8am-5pmSunMonTueWedThuFriSatDo you plan to work while enrolled in the internship program?* Yes No Name of Employer? Your Position Volunteer Experience*List experiences you have had as a volunteer in any type of service organization, including positions of leadership.Have you ever been convicted of a felony or subjected to a deferred adjudication on a felony charge?*If "Yes", please explain below. (You may omit convictions for minor traffic violations, unless the position for which you are applying requires the operation of a motor vehicle. Conviction will not result in your automatic disqualification for employment. The seriousness of the crime, the date of conviction, and the relevance of the crime to this position will be considered. Yes No ExplanationDo you speak a language other than English (if required for this position)? Yes No If "Yes", which language(s) do you speak? References*List three persons not related to you who are qualified to describe your capabilities for this intern position.NameAddressPhoneOccupation Goals & Expectations*Please submit a statement reflecting what expectations and professional goals you have for yourself following graduation and how your placement in the internship program may directly benefit you in realizing these objectives.Background Check/Drug Screen Authorization*I authorize CVCSCD/CCF to complete a computerized criminal history search of my background, a drug screen, and any other inquiry that should be deemed appropriate to the approval of this application.CONCHO VALLEY CSCD/CCF CONFIDENTIALITY AGREEMENT*The Concho Valley CSCD/CCF has access to information of an extremely confidential nature. As custodian of this information, CSCD/CCF must do everything possible to ensure its safekeeping. Information is considered to be any knowledge, documentation or opinions gathered by this department or its representatives. All information regarding persons receiving the services of CSCD/CCF is confidential, except where provided by law, whether or not the individuals are on community supervision. Release of any confidential information, except under the specific circumstances allowed by this department, will be prosecuted to the full extent of the law. In addition to legal prosecution, a breach of confidentiality is grounds for termination from any employment agreement with this department, paid or voluntary. I have read this Confidentiality Agreement and agree to keep confidential any information to which I have access, while active and after I leave my position with CSCD/CCF.CONCHO VALLEY CSCD/CCF RESIDENT RELATIONSHIP ACKNOWLEDGEMENT*Relationships between representatives of CVCSCD/CCF and the residents of CVCSCD/CCF are to remain “professional” at all times. By mandate of Texas Penal Code Section 39.04, it is a State Jail Felony offense for an employee, volunteer, intern, peace officer, or vendor of a correctional facility to engage in sexual contact, sexual intercourse or deviant sexual intercourse with an individual in custody. If such a complaint is made a full investigation will take place. If it is determined that the complaint if valid, the appropriate law enforcement agency will be notified and it will be grounds for immediate termination of employment, volunteer services, intern services, or contract services. By my signature below, I acknowledge that I have been informed of this regulation and agree to refrain from any improper relationship and/or contact with the residents of Concho Valley CSCD/CCF.PREA Standards § 115.217 Requires the following questions about misconduct:(1) Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. § 1997)?* Yes No (2) Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?* Yes No (3) Have you been civilly or administratively adjudicated to have engaged in the activity described in question (2)?* Yes No Form SecurityCommentsThis field is for validation purposes and should be left unchanged. Menu LinksCJAD Tom Green county District Courts Texas CSCD Directory
