Application Download and submit the application along with your resume OR complete the form below. Practicum Student Profile "*" indicates required fields Name* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Are you located in the St. Louis area? (Please note we currently do NOT accept remote students)* Yes No Connection to Long-Term Care (check all that apply)* Family Member Community Volunteer Healthcare Professional Student (I am interested in learning more through service.) Which family member resides in long-term care? Do you have a family member employed by a long-term care facility?* Yes No Which facility? Do you need this position to fulfill mandated community service hours, an internship, or practicum?*(please select from below)YesNoIMPORTANT: If you do not need to fulfill community service hours, do not need an internship or a practicum, but you are interested in volunteering with VOYCE, please do not submit this form. You can learn more about our volunteer opportunities here: Which of the following are you looking for?(please select from below)Community Service HoursPracticumInternshipWhat areas are you seeking to serve in? (check all that apply) Ombudsman Clinical (micro advocacy) Long-Term Care Policy (macro advocacy) Nonprofit Marketing and Social Media Grass Roots Organizing Nonprofit Volunteer Coordinating School or Organization* Degree and/or Program* Hours Needed* Approximate Start Date (Month and Year)* Have you ever been convicted of a felony?* Yes No Ethnicity African American American Indian or Native American Asian Caucasian Eastern Indian Hispanic or Latin American Pacific Islander Other Prefer Not to Answer To improve our services and identify the ethnic groups that our volunteers represent, VOYCE collects the following demographic information. This information is optional and does not affect volunteer placement in any way. Emergency Contact Information First Last PhoneRelationship to Student Resume*Max. file size: 10 MB.Please upload a copy of your resume.Confidentiality Agreement Consent* By checking this box, I agree to VOYCE’s Statement of Confidentiality as written below.Confidential information is personal information that you have shared with VOYCE for the purpose of service delivery. You have the right to have such information safeguarded by VOYCE staff and volunteers. VOYCE shall maintain confidentiality as follows: 1. All written and electronic records that identify individual service recipients and donors are confidential and may be used by designated staff and volunteers for the services, program monitoring and/or development purposes only. 2. Records that identify individual recipients and donors shall not be available to any other individual, agency or organization without either written permission from the recipient, donor, legal representative of the individual or judicial process. 3. Computer access to confidential records will be safeguarded through restricted file access limited to designated staff and volunteers. 4. Upon termination of my service/employment, I will deliver to VOYCE, and not keep or deliver to any other person or entity, any and all items and copies of items containing confidential information. I have read and agree to comply with the VOYCE policy regarding confidentiality. I agree to abide by federal HIPAA law. Information regarding HIPAA law can be found here: https://www.hhs.gov/hipaa/index.html and https://www.cdc.gov/phlp/publications/topic/hipaa.html Δ
