Volunteer Application Form

Name*

First Last

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Enter Email Confirm Email

Date of Birth*

Employer/School

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship*

References

Please list two professional references we may contact:

1st Reference Name*

First Last

1st Reference Phone*

1st Reference Email*

1st Reference Relationship*

Second Reference*

First Last

2nd Reference Phone*

2nd Reference Email*

Relationship to 2nd Reference*

Background Information & Experience

How did you hear about Full Circle?*

What do you hope to gain out of your volunteer experience?*

Please list any health problems, allergies (food, medication, other) or other information that may be helpful in an emergency:*

Please describe your educational, professional, or volunteer experience:*

List any hobbies, interest, or skills:

Areas of Interest

Areas of Interest (Check all that apply):

Adult and Family Counseling Groups (Hands on Healing, Suicide Loss Group, Perinatal Loss Group) - 8-week counseling groups, 2 hours per week in the evening.
School Groups - 8-week counseling groups, 1-2 hours per week during the school day.
Community Partnership Youth Groups - 8-week counseling groups, 1-2 hours per week in the afternoon or evening, in partnership with organizations like The Virginia Home for Boys & Girls and Friends Association for Children.

Please check all that apply.

Age Group You Prefer to Work With (Check all that apply)

Preschool
6-11 year olds
Pre-teens
Teenagers
Young Adults

Community Outreach (Check all that apply):

Awareness Events - 1-time events usually on the weekends at community events. Oversee craft and distribute promotional materials. 2-hour commitment, schedule as requested.
Remembrance Events - 1-time events usually at schools during the school day, 2 hour commitment, scheduled as requested.
Fundraising Events - Incorporate fundraising into your activities with our help.
Supply Drive - Coordinate an art supply drive in your community with our help.
Circle of Giving - Contribute to a gift presented to each family at the conclusion of their 8 week group.

Event Support (Check all that apply):

Round Up the Family Fun Run - Family fun fundraising event in the spring, varied opportunities.
Live Your Dash Luncheon - Spring luncheon event with inspirational keynote speaker and community awards.
Full of HeART Auction & Cocktail Party - Adult fundraising event in the fall, varied opportunities.

Administrative

Art preparation for groups, office organizations, copying, filing, mailings, etc.

Volunteer Requirements, Commitments, and Acknowledgement

At Full Circle Grief Center, we will frequently be observers and recipients of confidential information concerning participants and their families. Facts or situations in the participant’s life will be communicated, with the implicit understanding that this information will not be shared with others.

Confidentiality is the preservation of information concerning participants in our programs. It is based upon the basic right of privacy and is an ethical obligation of the clinician. Confidentiality is essential to building the trust of the members and creating a safe environment for feelings to be shared.

As clinicians and volunteers, we will share information about group participants during the group debriefing periods. As staff members, we will share information during internal consultations and clinical meetings. When participants come to Full Circle, they review the “Exceptions to Privacy”, which outline times like this when their information is shared with others within the organization. This sharing between the staff, clinicians, and volunteers is essential to making sure we are meeting the needs of the families in the best way possible.

All staff members, clinicians, and volunteers are bound by confidentiality to not discuss information about any family with anyone except staff members or contract clinicians and volunteers participating in your current group/program. If you are a student and are utilizing your volunteer experience for school credit, please do not discuss the name of the family or any details about the death with your professor or classmates. Doing so would be a violation of confidentiality.

Confidentiality will always be preserved, with the exceptions noted below.

The above mentioned may occur in pre and post meetings or debriefing periods. Please initial below to acknowledge your understanding and agreement.*

If we learn that someone with whom we are working has a specific intent to bring harm to himself/herself, we reserve the right to inform other family members and/or make appropriate referrals if necessary.*

Please initial to acknowledge.

If we have reason to be concerned about the drug and/or alcohol use or abuse by a child or teen, we reserve the right to inform the parent. If we suspect a participating adult is using drugs and/or alcohol before a group, we reserve the right to speak to that adult.*

Please initial to acknowledge.

If information is ordered by the court, including a subpoena, we will attempt to contact the individual about the order. If they oppose the release of information, the court may nevertheless require compliance with the order.*

Please initial to acknowledge.

If we learn that someone participating in the program intends to commit a violent act, we may take steps to protect the intended victim against such danger, or inform the police, or both*

Please initial to acknowledge.

Before you take any action to break confidentiality, please contact Allyson Drake, Full Circle’s Executive Director or your Program Director.

AUTHORIZATION/CONSENT
FOR BACKGROUND VERIFICATION DISCLOSURE

During the application process and at any time during the tenure of my employment/service with Full Circle Grief Center, I hereby authorize ChoicePoint Services Inc., on behalf of Full Circle Grief Center to procure a consumer report which I understand may include information regarding my character, general reputation, or personal characteristics.

This is used to inform you that a consumer report is being obtained from a consumer reporting agency for the purpose of evaluating you for employment, volunteer service or a contracted position, including retention as an employee, volunteer or independent contractor.

I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, or personal characteristics.

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date*

SOCIAL SECURITY NUMBER*

BIRTH DATE*

SIGNATURE*

Post Title

Thank you for completing our Volunteer Application.

References

Background Information & Experience

Areas of Interest

Volunteer Requirements, Commitments, and Acknowledgement

AUTHORIZATION/CONSENT
FOR BACKGROUND VERIFICATION DISCLOSURE

UPCOMING EVENTS

UPCOMING PROGRAMS

RECENT ARTICLES

Instagram

fullcirclegriefcenter

Contact Us.

Donate.

Email Contact: Allyson@fullcirclegc.org

Volunteer Application Form

Thank you for completing our Volunteer Application.

References

Background Information & Experience

Areas of Interest

Volunteer Requirements, Commitments, and Acknowledgement

AUTHORIZATION/CONSENTFOR BACKGROUND VERIFICATION DISCLOSURE

UPCOMING EVENTS

UPCOMING PROGRAMS

RECENT ARTICLES

Instagram

fullcirclegriefcenter

Contact Us.

Donate.

Email Contact: Allyson@fullcirclegc.org

AUTHORIZATION/CONSENT
FOR BACKGROUND VERIFICATION DISCLOSURE