Circles of Support Volunteer Form Circles of Support Volunteer Application Volunteer InformationLast name First name Other names used AgeGenderMaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home phoneCell phoneEmail Referred by, if applicable EducationSelect highest grade completedHigh schoolSome collegeVocational or technical trainingCollegeGraduate schoolMajor Degree List any certifications, licenses, or other special skills Current EmploymentCurrent/ last employer PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Other InformationAre you a part of a faith community (church, mosque, synagogue, etc.) that is creating a faith group circle? Yes No What is the name of the faith community? Hobbies, clubs/organizations, athletics, etc.What attracted you to volunteer with COS?What do you hope to offer, and to gain?What days/times would you be available for a one-hour weekly commitment? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you have any other circumstances in general which might affect the quality or frequency of your volunteering? If yes, please explain:References: Professional or Your Faith CommunityList two persons who are not related to you that you have known for at least one year and would be willing to give a personal reference. Please fill in complete name, address, or email address. Letters will be mailed/emailed to each of these references.Reference 1Full name Relationship Years knownAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home phoneWork phoneCell phoneEmail Reference 2Full name Relationship Years knownAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home phoneWork phoneCell phoneEmail IMPORTANT: Answers to any of the above questions that may seem negative will not automatically disqualify your application. As an agency committed to preserving the integrity of the Circles of Support (COS) program, these areas must be explored and are not intended to offend or invade the privacy of the applicant. All information is confidential and will only be viewed by or shared with the leadership of the COS program.Consent I agreeChecking I agree hereby certifies that all the above statements are true to the best of my knowledge. I understand that any misrepresentation may justify my dismissal from the Circles of Support program. I understand and agree that any, and all knowledge or information obtained in the course of my work with the COS program, with respect to the conduct and details of the participant and other volunteers, will be forever held inviolate. I understand and agree that I will not impart the knowledge and information shared within the circle outside of COS policy. I understand, and personally assume all responsibility for the volunteer relationships between myself and the other circle members and participants. I agree to hold the Circles of Support program, the County Sheriff’s Department and Jail, the State Department of Corrections, and La Crosse Jail Ministry harmless for any actions of a participant, other member, or myself.Name Date MM slash DD slash YYYY Untitled Δ
