First Name:

Last Name:

Middle:

Address:

City:

State:

ZIP:

Date of Birth:(mm/dd/yy)

Email Address:

Cell Phone:

Other Phone:   Home Work

Occupation/Employer:

Emergency Contact:

Phone 1:

Phone 2:

Have you in the past or do you use any names other than the one listed on this application?

Yes

No

If yes, please list here: (Include maiden name.)

Have you resided in any state besides Wisconsin in the past 5 years?

Yes

No

If yes, please list here: (Include approximate date(s) of residence.)

Volunteer Interests (Check all that apply):
PARENT STRESSLINE: Parent Stressline	OTHER: Office Support
OASIS SEXUAL ABUSE TREATMENT GROUPS: Adult Group Tue. 5:30-7pm Adult Group Thu. 5:30-7pm Teen Group Tue. 5:30-7pm Teen Group Thu. 5:30-7pm Youth Group Tue. 5:30-7pm Youth Group Thu. 5:30-7pm	F.U.N. SUPPORT GROUPS: Parent Group Mon. 6-8:45pm Parent Group Weds. 6-8:45pm Teen Group Mon. 6-8:45pm Teen Group Weds. 6-8:45pm Youth Group Mon. 6-8:45pm Youth Group Weds. 6-8:45pm Young Children Weds. 6-8:45pm Young Children Weds. 6-8:45pm
CHILDCARE: Tues. 5:30-7:15pm Thurs. 5-7:15pm	MEALS (Sereve & Clean Up): Mon. 5:15-7pm Wed. 5:15-7pm

1. How did you hear about us?
    

2. Have you had any experience that relates to child abuse? Yes No
    If yes please explain:
    

3. Please describe any experience that you have had with severe stress or crisis.
    

4. Please describe any previous experience or training that relates to the volunteer
    position for which you are applying:
    

5. What hobbies, interests, special talents or training can you bring to this position?
    

6. Please complete this sentence:
    "When I think of an abusive parent I...
    "

7. Do you speak any languages aside from English?    Yes    No
    Please list:

Please list three references. At least one should be of a professional nature.
Email addresses are preferred.

1. Reference Name:		Phone:
Relationship:		Email:
2. Reference Name:		Phone:
Relationship:		Email:
3. Reference Name:		Phone:
Relationship:		Email:

OPTIONAL INFORMATION

Organizations that provide funding for our programs occasionally request demographic information about our volunteers. Answers to the following questions would be helpful, but not required. Any information you provide will not be used to determine your suitability as a volunteer.

Your Gender: Male     Female

Your Age: Under 18     18-59     60+

Your Race/Ethnicity:
White     Black     Hispanic     Asian/Pacific Islander
Native American     Multi-Race

Do you consider yourself to be a "person with disability" (physical or mental impairment which substantially limits one or more life activities)? Yes No

Signature (Type in your name.) 

Signature Confirmation: What is your favorite color?  

By submitting this form, I authorize the Canopy Center to proceed with a criminal background check and to check my references (required of every staff member and volunteer). I also certify that all of the above information is true and correct to the best of my knowledge. (Submitting your signature and signature confirmation electronically is considered the same as a hand-written signature.)


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