Volunteer Application Form Name* First Middle Last Date of Birth* Address* Street Address Address Line 2 City ZIP / Postal Code Primary Phone*Secondary PhoneEmail* Drivers License Number*Drivers License Expiration Date* Have you ever committed a felony (A crime punishable by imprisonment in state prison)?*YesNoHave you ever committed a misdemeanor (Any other crime but not traffic offenses)?*YesNoHave you ever been arrested and/or convicted of a felony?*YesNoHave you ever been arrested and/or convicted of a misdemeanor?*YesNoAre you currently employed?*YesNoIf yes, description of employment:List any languages, other than English you speakList any special skills, training, interests, or hobbies that you have that may be useful to VCR Program:Education Background:*High School Diploma / GEDCollegeName of SchoolGraduation Date Degree ReceivedVolunteer ExperiencePlease list any other community activities:Share some of your personal experience with trauma and how this might influence your role as a VCR.Is there anything in your past that might disqualify you from functioning as a Victim Crisis Responder for the Fox Valley Police Departments?*YesNoIf yes, please describe briefly:Work ExperienceMost recent first--within the last fiver years)1. Employer/Supervisor1. Phone Number1. Duties2. Employer/Supervisor2. Phone Number2. Duties3. Employer/Supervisor3. Phone Number3. DutiesI heard about the VCR program through:List 3 personal references other than family: First Last PhoneRelationshipName First Last PhoneRelationshipName First Last PhoneRelationshipIn case of emergency, please contact:Name* First Last Phone*Relationship to Volunteer:*Provide A Brief Personal History along with a description of interests in the program. Then explain what you would like to learn during the training sessions.*Release of Information StatementElectronic Signature* First Last Release of Information Statement Electronic Consent* I consent NameThis field is for validation purposes and should be left unchanged. Δ
