Volunteer Facilitator Training Application Survey

1. Please tell us about yourself:

Please tell us about yourself: Name:
Birthdate:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Home Phone Number:

2. More contact information:

More contact information: Cell Phone Number:
Emergency Contact Name:
Emergency Phone Number:
Your Employer/School:
Work Phone:

3. Training Dates Requested:

Training Dates Requested: October 13, 14 & 27, 2012

4. The Dougy Center has three locations, please indicate where you are available to volunteer. (Check all that apply)

The Dougy Center has three locations, please indicate where you are available to volunteer. (Check all that apply) Portland

Canby

Beaverton/Hillsboro

5. Below are the days, times, and locations for our groups, please indicate your availability. (Check all that apply)

Below are the days, times, and locations for our groups, please indicate your availability. (Check all that apply) PORTLAND (2228 NE Glisan)

Monday 3-6:30pm

Monday 5:30-9pm

Tuesday 3-6:30pm

Wednesday 12pm-3pm

Wednesday 3-6:30pm

Wednesday 5:30-9pm

Thursday 9am - 12pm

Thursday 3-6:30pm

Thursday 5:30-9pm

CANBY

Monday 5:30-9pm

Wednesday 5:30-9pm

Thursday 5:30-9pm

HILLSBORO

Monday 5:30-9pm

Tuesday 5:30-9pm

6. Please tell us about the deaths and other losses you have experienced:

Please tell us about the deaths and other losses you have experienced:

7. Please tell us your reasons for applying, including what you hope to gain personally from this training and being a volunteer facilitator at The Dougy Center:

Please tell us your reasons for applying, including what you hope to gain personally from this training and being a volunteer facilitator at The Dougy Center:

8. Describe any previous training you've had related to grief & loss:

Describe any previous training you've had related to grief & loss:

9. Describe your professional, personal, and/or volunteer experiences working with children, teens, & adults:

Describe your professional, personal, and/or volunteer experiences working with children, teens, & adults:

10. Please check below:

Please check below: I understand that I am required to attend all 22 hours (3 sessions) of the Volunteer Facilitator Training before I can become a facilitator in a Dougy Center group.

I understand that The Dougy Center reserves the right to accept or deny any potential trainee as a facilitator even after he/she completes the 3 sessions of training.

I understand that this training is offered only to those who intend to volunteer for at least one year as a facilitator of a group sponsored by The Dougy Center. Each group meets for 3.5 hours, every other week.

I understand that if I am accepted as a facilitator, I will be asked to complete a Background Check Disclosure Form.

I understand the fee for the training is $95.00. If I am accepted into a training, a $35 deposit will be required to hold my space. I will pay the remaining $60 prior to the first day of training.

I understand that applications are accepted on an ongoing basis. I will be notified 2 months prior to the next training dates about my application status. Trainees will be placed based on the needs of The Dougy Center and trainee's schedule availability and flexibility.

I understand that facilitating children may be physically active. I am physically able to climb stairs, sit on the floor and play actively.

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