Submitted by bill on Fri, 06/09/2017 - 12:49 1 Start 2 Complete Name * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * DayTime Phone Evening Phone Cell Phone Email Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 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). Submit