Application for Volunteer Training

Requested Training for the Volunteer Position (Select One)
	Helpline Volunteer (Description) Sexual Assault Specialist (Description) Reassurance Volunteer (Description)
Personal Information
	Name:			Address:
	City:			State:
	Zip:			E-Mail:
	Phone:			Work:
	Cell:			Gender: Male   Female
	Date of Birth:			Age:
	Emergency Contact:			Emergency Phone:
	Skills, Interests and Hobbies:
	Highest level of education completed: High School Graduate Community College Four Year College or University Degree Graduate Degree
	Additional education and/or training:
	Current employment status: Unemployed Part-Time Employee Full Time Employee Retired
	Name of Employer:			Job Title:
	Previous volunteer experience including location and dates:
	Have you taken ContactLifeline training in the past?  Yes   No
	If so, when?			Where?
	Reason for withdraw from the program:
	Write a brief statement explaining your  desire to volunteer for ContactLifeline:
	What are your strengths and limitations  relating to people in distress or crisis?
Background Verification
	Have you ever been convicted  of a criminal offense?			Yes   No
	Have you ever been charged  with neglect, abuse, or  assault?			Yes   No
	Has your driver’s license ever  been suspended or revoked in  any state?			Yes   No
	Do you use illegal drugs?			Yes   No
	Do you have any physical  limitations which might limit  your ability to perform  certain types of work?			Yes   No
	If you answered yes to any of these questions,  please offer a brief explanation:
	Background Checks will be performed before active service.
Availability & Commitment
	Are you willing to commit to the full 24 hours of training class  plus apprentice shifts followed by at least  one year of volunteer service to ContactLifeline (volunteering 8 hours per month) and mandatory  Advanced Training sessions quarterly?
	Yes   No
References
	List name and phone numbers of two  personal and/or professional references:
	Reference Name 1:			Phone:
	How many years known and in what capacity?
	Reference Name 2:			Phone:
	How many years known and in what capacity?
	I have read and agree to the statements below: Realizing that confidentiality is the cornerstone of the ContactLifeline program, I agree to keep any and all  information that comes to me during training in the  strictest of confidence.  I agree that I may be asked by the Program Director  to withdraw from classes at any time.  I also agree that in the event of my withdrawal or  resignation, I will keep confidential all information  related to the work of ContactLifeline.
	How did you hear about us?

Since 1974, 
ContactLifeline 
has responded 
to over 
900,000 calls - 
24 hours a day, 
7 days a week.