Facilitator/Volunteer Application

Personal Information

First Name *

Middle Name *

Last Name *

Birthdate *

Home Address *

Apt.#

Home Phone *

City *

ST *

Zip *

County *

Email *

Cell Phone *

Alt. Phone *

Sex *

Relationship Status *

Ethnicity *

Race *

Education/ Highest Degree Completed *

Employer: *

Occupation: *

May we contact you at work? *

yes

Employer Address: *

How long employed? *

Work hours/week: *

City *

ST *

Zip *

Work Phone *

What times are you available to volunteer?
Check all that apply. *

9a-5p

After 5p

Weekdays

Weekends

References

Please list three (3) references who have known you longer than one year and preferably can speak to your skills and abilities to communicate information and lead others in a group setting. Please clearly print names, telephone numbers (daytime, cell, etc), email and relationship to you. Do not include more than one family member.

1. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

2. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

3. Name *

Phone Number: *

Email or other # *

Address:

City, ST *

Zip

Relationship to you: *

How long has this person known you? *

Additional Information

What, if any, other organizations have you worked for or been involved with as a volunteer?

How did you hear about our program?

List other groups, associations, or churches you're involved with:

Do you have experience facilitating small groups? If yes, please explain. *

yes yes

Applicant Signature *

clear

date *

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