Survivors, Inc. Volunteer Application

All information on this form will be kept confidential. Please respond as accurately as possible.

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Cell Phone Number

Work Phone Number

Email Address

EMERGENCY CONTACT

Name

Phone Number

Relationship To You

QUESTIONAIRE

Are you over 18 years of age?

Education Level Completed

Employer

Volunteers interested in providing services to clients must complete a 64 hour training class. These classes are held on eight consecutive Saturdays in the fall and spring. What might interfere with your ability to attend these sessions?

How did you learn about Survivors, Inc?

Please list any skills you would contribute as a volunteer?

Tell us about your interest in working with victims of domestic or sexual abuse?

What expectations do you have about Survivors, Inc. or our volunteer program?

What do you hope to gain from this experience?

References

List 3 references not living in your household or in your immediate family:

Name

Phone Number

Relationship

How Long?

Name

Phone Number

Relationship

How Long?

Name

Phone Number

Relationship

How Long?

Indicates Response Required