Facilitator Application

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* 1. Program Location(s) Interested in Participating

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* 2. Contact Information

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* 3. I am a

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* 4. Date of Birth

Date / Time

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* 5. Highest Degree of Education

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* 6. Title of Degree

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* 7. Occupation

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* 8. Employer

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* 9. How did you hear about the CBC?

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

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

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

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

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

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

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

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* 17. 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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* 18. What languages do you speak?

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

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

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* 21. Are you abusing drugs or alcohol?

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

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

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

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* 25. Emergency Contact

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

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