Facilitator Application

* 1. Program Location(s) Interested in Participating

* 2. Contact Information

* 3. I am a

* 4. Date of Birth

Date / Time

* 5. Occupation

* 6. Employer

* 7. How did you hear about the CBC?

* 8. What made you decide to to volunteer at the CBC?

* 9. What are your expectations of participation in this program?

* 10. Is there anything likely to prevent you from keeping your one-year commitment? If yes, please explain.

* 11. Describe your experiences with youth/adult organizations (volunteer, professional, personal).

* 12. Are you active on any corporate or non-profit boards? If yes, which one(s)?

* 13. Which participants would you like to work with?

* 14. What is the reason for your preference above?

* 15. What hobbies, talents, or skills do you have that would be of interest to the CBC and which would you be willing to share?

* 16. What languages do you speak?

* 17. Please identify any physical or medical conditions that may affect your ability to participate in the peer support group.

* 18. Are you on public record as a sex offender or physical abuser?

* 19. Are you abusing drugs or alcohol?

* 20. Have you ever been hospitalized for mental illness? If so, when?

* 21. What deaths/losses have you suffered? Please list relationships and dates.

* 22. May we use your name/photo in our newsletter, website, or any other promotional materials?

* 23. Emergency Contact

* 24. Due to the nature of the Children's Bereavement Center peer support group program, we reserve the right to dismiss volunteers at any time.