Volunteer Application | RICK'S PLACE

Name *

Address *

City *

State *

Zip *

DayTime Phone

Evening Phone

Cell Phone

Email

Date of Birth *

Month

Day

Year

Emergency Contact *

Serious Medical Conditions *

How did you hear about volunteering at Rick’s Place

Employment/Volunteer History *

Have you ever been convicted of a felony? *

No

Yes

Felony Explanation

Have you ever been arrested for a sex offense or physical assault? *

No

Yes

Arrest Explanation

I am willing to commit to Rick’s Place for one complete “season”. *

No

Yes

I am willing to commit to Rick’s Place for one complete “season”, will be present for 4 hours at each session, and have a maximum of 2 absences.

I can commit to additional volunteer hours (up to 1 hour) for group planning *

No

Yes

I am available to help out in other ways (i.e. event planning, outreach) *

No

Yes

I hold up-to-date certification in CPR/First Aid *

No

Yes

Please list all education and experiences (work or volunteer) with children. Please include teaching, childcare, camp counseling etc. *

Please tell us why you are interested in volunteering at Rick’s Place. *

Have you had a family member or close friend die within the last year? Please explain. *

Have you been affected by another kind of major loss or change with the last year? Please explain. *

Have you had a family member/close friend die or another kind of major loss or change within your life? *

Have you ever had first-hand experience with counseling or support groups? *

Reference #1 *

Reference #2 *

Because our first concern must be the families who come to Rick’s Place, we reserve the right to decide whether an applicant would fit with our program needs. By signing this application, you are agreeing to that policy as well as to reference and background checks.
While a facilitator at Rick’s Place, you are agreeing not to date Rick’s Place family members and to participate in all Rick’s Place activities drug and alcohol free.
Further, you are confirming that all statements made on this application are correct and that you know of no reason that would prevent you from being a qualified facilitator at Rick’s Place.
Finally, you are acknowledging that acceptance to the Rick’s Place volunteer training does not guarantee a position as a Rick’s Place facilitator.

If you agree to these conditions of application, please sign below.

Signature *

I understand that typing my name constitutes a legal signature and confirmis that I acknowledge and agree to the above Conditions of Application.

Note: Practicing therapists and counselors will be asked to make a deposit of $ 100 for the initial facilitator training,
which shall be refunded if the therapist/counselor completes one year of service with the program or at the Director’s
discretion (if there is agreement not to continue the volunteer’s relationship with Rick’s Place).