Facilitator Application

Program Location(s) Interested in Participating

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* 1. Program Location(s) Interested in Participating

Contact Information

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* 2. Contact Information

I am a

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* 3. I am a

Date of Birth

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* 4. Date of Birth

Date / Time
Highest Degree of Education

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* 5. Highest Degree of Education

Title of Degree

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* 6. Title of Degree

Occupation

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* 7. Occupation

Employer

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* 8. Employer

How did you hear about the CBC?

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* 9. How did you hear about the CBC?

What made you decide to to volunteer at the CBC?

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

What are your expectations of participation in this program?

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

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

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

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

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

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

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

Which participants would you like to work with?

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

What is the reason for your preference above?

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

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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* 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?

What languages do you speak?

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* 18. What languages do you speak?

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

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

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

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

Are you abusing drugs or alcohol?

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* 21. Are you abusing drugs or alcohol?

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

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

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

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

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

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

Emergency Contact

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* 25. Emergency Contact

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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* 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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