This is a Volunteer Application for those who are at least 18 years or older and would like to volunteer at the Crisis Center.  Please complete the application as thoroughly as possible. We will contact you soon after we receive it.  Thanks!

***Caution: Use TAB key or mouse to move from field to field.  Hitting ENTER will submit the form half done. Oops!   If that does happen, just hit the back key and complete the form. ***

Date (MM/DD/YY):

Last Name:

First Name:

Middle Initial:

Preferred name or nickname:

E-mail address:

Your Address

Street:

City:

State:

Zip Code:

If you would feel more comfortable, you can stop here and we will send you a form to fill out. Otherwise, please continue and we'll be in touch with you soon to set up an interview.

Telephone Numbers (enter with area code like this): xxx-xxx-xxxx

Home:     Best Time to reach you:
Work:      Best Time to reach you:

Gender: male female  (Click on one using your mouse)

Age: Date of birth (MM/DD/YY):    T-Shirt Size

Marital Status: (Choose one using your mouse)
Number of children:

Presently employed at:
Occupation:
Full time Part time Summer only Not at all

Presently in school at:
Major/Minor:
Full time Part time Summer only Not at all

In case of emergency, who should be notified?
Name:
Relationship:
Address:
Street:
City:
State: Zip Code:
Home Phone (xxx-xxx-xxxx):
Work Phone (xxx-xxx-xxxx):

How long have you lived in the Lafayette area?

What work-related or volunteer experiences, hobbies or specialized skills do you have that might be helpful for work as a Crisis Center Volunteer?  (Write as much as you like as these boxes expand to hold what you write.  No need to use ENTER key here but if you do, you won't get bumped like in other fields.)

Describe any personal experiences you have and which you think would help you be an effective and empathic listener. Also describe what you learned about yourself and others through these experiences.

What do you expect to gain for yourself by working at the Crisis Center (i.e. personal, academic requirements, job skills, etc)?

How did you learn about the crisis center?

If other, please specify:

After successful completion of training, Crisis Center volunteers make a commitment to work 39 four-hour shifts (about one shift a week) at the Crisis Center within one year after training. Volunteers are scheduled in advance according to times they indicate they are available. Please answer the following (using your mouse):

1. I intend to work at least one shift per week for at least 39 shifts: Yes No
2. If I am unable to work a shift for which I am scheduled, I will take responsibility for finding a Crisis Center volunteer to replace me for that shift: Yes No
3. I will be available to work shifts during the summer months: Yes No

Thank you for taking the time to fill out this form. The Crisis Center will be getting in touch with you soon to set up an interview.

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