Facilitator Application Survey

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* 1. Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Date of Birth

Date / Time

Date

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* 3. Pronouns

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* 4. Gender

Female

Male

Non-Binary

Prefer not to say

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* 5. Race/Ethnicity

African American/Black

American Indican/Alaskan Native

Asian

Hispanic/Latinx

Native Hawaiian/Pacific Islander

White Non-Hispanic

Multicultural

Other

Prefer not to say

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* 6. Highest Degree of Education

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* 7. Employer

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* 8. Title of Degree

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* 9. Occupation (LMHC, LCSW, Nursing, Marketing)

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* 10. Professional License Number (if applicable)

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* 11. How did you hear about the CBC?

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* 12. What made you decide to to volunteer/work at the CBC?

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

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

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

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

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

Elementary Age (K - 2nd Grade)

Elementary Age (2nd - 5th Grade)

Middle School

Teens

Adults

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

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

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* 20. What languages do you speak?

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

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

Yes

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* 23. Are you abusing drugs or alcohol?

Yes

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

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

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

Yes

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* 27. Emergency Contact

Name

Relationship

Phone Number

Email Address

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

I agree

I do not agree

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* 29. All staff are required to complete a background and fingerprint check.

I agree

I do not agree