Fr ffice use nly: Entered in Cmputer By Nrthern Illinis Fd Bank Curt-Cmpelled Individual (CCI) Frm Date Entered Date: Cntact Infrmatin (Required) Yes, I am ver 16 years ld (Date f Birth: (As a minr, please nte that yur parent/guardian must sign yur intake frm. The CCI participant must be respnsible fr cmmunicating scheduling needs, verificatin f hurs, and any unfreseen absences t the CCI Crdinatr befre the absence.) Yes, I am ver 18 years ld Applicant: Male Female First Middle Last Address: Street Apt. City State Zip Cde Telephne N.: ( ) - Primary ( ) - Secndary Cunty: E-mail: Curt Mandated Cmmunity Service Infrmatin (Required) Nrthern Illinis Fd Bank Lcatin where I wish t cmplete my curt mandated hurs: West Suburban Center Geneva Nrth Suburban Center Park City Nrthwest Center Rckfrd Ttal Hurs Due: Due Date: / / Next Curt Date: / / Case Number: First Offense: Yes N Descriptin f the Offense: If this is nt yur first Offense, please list any and all prir Offenses: The fllwing items are required in rder t start shifts with Nrthern Illinis Fd Bank 1
If yu are unable t prvide these items, yu will nt be able t perfrm any scheduled hurs. A COPY OF A COURT DOCUMENT OR TICKET stating yur ffense is required by yur first vlunteer shift. Yu MUST have a pht ID with yu n yur first shift. Paperwrk is included with this intake frm: Yes N Have yu ever cmpleted Curt-Cmpelled Service at Nrthern Illinis Fd Bank befre: Yes N If yes, when/where: Hw did yu hear abut Nrthern Illinis Fd Bank:. A letter verifying yur hurs can be prvided upn request. Yu must cntact Barb Lchmann at blchmann@nrthernilfdbank.rg r 630.443.6910 ext. 110 t receive a letter. Letters are ONLY sent ut when requested by the CCI participant. Yu must prvide at least three business days t receive a letter. Please prvide the infrmatin belw if yu need a letter sent directly t smene ther than yurself. Name f Recipient f Curt Letter: Mailing Address r Fax Number fr Curt Letter: Are yu able t lift up t 30 punds: Yes N Additinal Infrmatin (Required) D yu have any physical limitatins which might limit yur ability t perfrm certain types f wrk: Yes N If yes, please describe: Vehicle Infrmatin (Required) Make: Mdel: Year: Clr: License Plate N.: *All Curt Cmpelled Individuals are required t cmplete brief safety training n the first scheduled shift. Safety Guidelines Please be aware f yur surrundings: * Avid areas when equipment is being used by staff * D NOT run in the Warehuse T ensure safety please DO NOT: * Step n wden pallets * Lean int an empty tte (large bx) * Balance a tte n its side * Perfrm a task yu have nt been trained n by staff * Attempt t perate any machinery 2
YOU MUST ALWAYS: * Be asked by Fd Bank staff t perfrm a task d nt perfrm any tasks that yu have nt been asked t d * Please ask when yu have questins we are happy t assist yu during yur time here * Only perfrm the tasks that Fd Bank staff have trained yu t d * Ntify us f any limitatins r cncerns yu may have prir t perfrming a task The Fd Bank wants t make yur time with us as safe as pssible. Take yur time when perfrming yur assigned tasks and please ask fr any additinal training if yu need it. Please use extreme cautin while perfrming all tasks! Nrthern Illinis Fd Bank DOES NOT ASSUME ANY RESPONSIBILITY IF YOU ARE INJURED at any time during yur cmpletin f yur curt mandated hurs. Nrthern Illinis Fd Bank Curt-Cmpelled Individual (CCI) Cnsent Frm I understand my curt hurs at Nrthern Illinis Fd Bank may invlve wrking in warehuse cnditins and may smetimes include but are nt limited t: lifting, wrking arund heavy mving equipment, cleaning, and/r handling fd prducts. I am expected t fllw safety rules and all ther rules related t the warehuse. I hereby accept and assume full respnsibility fr any injury I might suffer while wrking at Nrthern Illinis Fd Bank. Nrthern Illinis Fd Bank will take all precautins t prvide and maintain a safe envirnment fr all Curt-Cmpelled Individuals. Participants are expected t fllw safety rules and all ther rules related t the warehuse. Nrthern Illinis Fd Bank accepts n liability fr individuals wh are cmpleting hurs with this prgram. If at any time yu cannt cmplete the task given, yu must reprt it t yur direct supervisr. I acknwledge having read and understd the abve cnsent frm n this date:, 20. Curt-Cmpelled Individual Signature Parent r Guardian signature if under 18 In Case f Emergency, Cntact: Name: Primary Phne: PLEASE PRINT Relatinship: Secndary Phne: PLEASE PRINT 3
Nrthern Illinis Fd Bank Curt-Cmpelled Individual (CCI) Guidelines Nrthern Illinis Fd Bank prvides the pprtunity fr individuals t cmplete their mandated cmmunity service hurs at ur facilities. Nrthern Illinis Fd Bank has the right t preclude yu frm cmpleting hurs at ur site if yu d nt cmply with the fllwing guidelines. 1. Requirements: Yu must meet the fllwing three requirements t cmplete hurs at the Fd Bank: i. Be 16 years f age r lder. ii. Be able t cmplete physical tasks, including but nt limited t: standing n yur feet in excess f fur hurs and/r lifting bxes f up t 30 punds. iii. Be cmpleting hurs fr an accepted ffense. Per ur prgram plicy, we d nt allw individuals t cmplete hurs at ur sites fr ffenses related t theft r thse f a vilent r sexual nature. 2. Scheduling: a. Yu MUST schedule yur hurs with the CCI Crdinatr. Yu cannt schedule shifts nline. It is nt acceptable t shw up unannunced and expect t wrk that day. Yu will need t set up yur schedule by calling r emailing the CCI Crdinatr t arrange a schedule. b. One N Call - N Shw day autmatically precludes yu frm cmpleting yur mandated hurs at Nrthern Illinis Fd Bank. Repeated changes t yur schedule r cancelling f shifts will als preclude yu frm cmpleting yur mandated hurs. c. If yu chse t cmplete hurs at a different lcatin, please cntact the vlunteer crdinatr t let them knw yu will n lnger be serving hurs at the Fd Bank. d. Yu will fllw the agreed-upn schedule and ntify the CCI Crdinatr f any changes at least 24 hurs in advance, unless it is an emergency. Call if yu will be late fr any reasn. Yu must cnfirm with r leave a message fr the CCI Crdinatr. In the event that the CCI Crdinatr is nt in the ffice, call the main number and leave a message with the receptinist t ensure yur supervisr is aware f the change. Please be sure that bth the CCI Crdinatr and Frnt Desk have received yur message. e. Yu MUST sign IN and OUT n the CCI sign-in sheet, listing the time yu arrive and the time yu depart. If yu d nt sign in/ut, yur hurs will nt be recrded. Any fraudulent recrding will preclude yu frm cmpleting yur mandated hurs at Nrthern Illinis Fd Bank. f. After signing in, yu will reprt t the apprpriate supervisr t receive yur assigned task fr the day. Each task will be dne in a timely manner. Yu shuld reprt back t yur supervisr after cmpleting each task r if yu have questins regarding it. 3. In the case f inclement weather, yu may access ur emergency/weather advisry extensin by calling ur main headquarters at 630/443-6910 ext. 183. A message will then advise yu f the Fd Bank s peratinal status. Unless the Fd Bank is clsed fr the day, yu must call the CCI Crdinatr t cancel yur scheduled shift. 4. On-site guidelines: N matter yur prject, yur supervisr must knw where yu are at ALL times while yu are cmpleting yur mandated hurs at Nrthern Illinis Fd Bank. If, at any time, yu are bserved by any Fd Bank emplyee litering, nt wrking n the task assigned t yu, taking excessive breaks, r simply wasting time, yu will be asked t leave the Fd Bank and will nt be permitted t return t cmplete yur mandated hurs. Yur cmmunity service supervisr will be ntified accrdingly. 4
5. Breaks Shifts are arranged in fur hur increments. Yu are allwed ne 15-minute break per 4 hurs f wrk. Break times are scheduled halfway thrugh yur shifts and are t be taken in the break rm r the smking area utside. N additinal smke breaks are allwed. Individuals wrking a full day are required t take a mandatry thirty minute lunch. Yu must sign in and ut fr lunch, as yu d nt receive credit fr this time. Yu may either take yur lunch in ur break rm r leave the building during this time. It is yur respnsibility t reprt t yur supervisr befre and after each break r lunch. 6. Dress Cde Yu must wear apprpriate attire while perfrming cmmunity service hurs pursuant t ur dress cde requirement. Requirements include: N sandals, flip-flps, heels, slippers, r pen-ted shes. N clthing with bscene slgans/lgs r cntrversial messages. N excessively baggy/lse clthing r dangling jewelry. N visible undergarments. Shrts are permitted, but shuld be mid-length t the knees. Shrt shrts are nt allwed. Our warehuses are nt temperature cntrlled. Please be sure t dress cmfrtably and apprpriately fr the current weather cnditins. Please bring a sweater in the event that yu wrk in the cler. Individuals wh d nt adhere t this plicy will nt be allwed t cmplete service hurs that day. Cntinued failure t adhere t this plicy will result in dismissal frm the wrksite. 7. Warehuse Rules: a. There is abslutely NO SMOKING in the building at anytime. Yu may nly smke in the utside designated smking area during yur designated break r lunch. b. Abslutely n fd and/r ther prducts are t be taken frm the Fd Bank fr yur persnal cnsumptin r use. If yu are in need f fd assistance, we will gladly direct yu t a pantry in yur area. Water and cffee are available fr yu during yur break/lunch. These items can be fund in the break rm and may nly be cnsumed during these designated times. c. Abslutely n fd and/r beverages are allwed in the warehuse. These items can nly be cnsumed in designated areas during yur designated break/lunch. d. Yu are respnsible fr cleaning up after yurself after lunches and breaks. Yu are als respnsible fr perfrming any clean-up duties as they pertain t specific tasks that yu are asked t cmplete. e. N ipds, MP3 players, r any ther devices using headphnes are permitted t be used during the wrk day. g. Cell phne use is nly permitted during break time r during the lunch hur. Cell phnes are t be turned ff during the wrk shift and are nt allwed in the warehuse r any wrk areas. h. There is ABSOLUTELY n use f any alchlic r nn-prescriptin substances n Nrthern Illinis Fd Bank premises. If yu are suspected f being under the influence f a substance, 5
yu will be asked t leave the premise and will nt be permitted t return t any Nrthern Illinis Fd Bank lcatin. i. Any illegal acts are subject t being reprted t the apprpriate authrities. Theft will nt be tlerated. If yu are suspected f taking any prducts frm the warehuse, ffice area, r Fd Bank vehicles, yu will be asked t leave the premise and nt be permitted t return t any Nrthern Illinis Fd Bank lcatin. j. Due t a lack f strage space, we suggest keeping all persnal items (wallets, cell phnes, etc.) either with yu r at hme/in yur persnal vehicle. A lcked clset is available fr yu t stre yur persnal items; hwever, Nrthern Illinis Fd Bank is nt respnsible fr any lst r stlen items. k. Participatin in any type f ffensive r harassing behavir will prhibit yu frm cmpleting yur mandated hurs at ur sites. Nrthern Illinis Fd Bank is cmmitted t prviding an envirnment that is free frm harassment based upn a persn s status (ie: gender, sexual rientatin, race, religin, age, disability, and additinal categries prtected under law.) Offensive and harassing behavir will nt be tlerated. I have read the guidelines t fulfill my hurs at Nrthern Illinis Fd Bank. I agree t adhere t all guidelines as stated. I understand that I will nt be allwed t cmplete my mandated hurs at Nrthern Illinis Fd Bank if I fail t cmply with any f these guidelines. Curt-Cmpelled Individual Date Parent r Guardian signature if under 18 years ld Date CCI Crdinatr Date 6