--Please Print this form on your printer, fill out the blanks and return it to the center.-- RAPE CRISIS CENTER, BRAZOS VALLEY P.O. BOX 3082, BRYAN, TEXAS 77805
For questions concerning application process, please call: (979)731-1000 ADVOCATE APPLICATION (Must Complete All Questions)
RAPE CRISIS CENTER BRAZOS VALLEY
ADVOCATE APPLICATION
* To be completed by prospective volunteer
Today's Date: ____/____/____
Name: ______________________________________________________________________________________________________
First Middle Last (Maiden)
Current Mailing Address: ________________________________________________________________________________________
Street City State Zip
Permanent Mailing Address: _____________________________________________________________________________
(if different) Street City State Zip
Date of Birth: ___________________________ Marital Status:_______________________________
Social Security #:________________________ DL # and State: _____________________________
Home Phone: ___________________________ Work Phone: ________________________________
Cell Phone: _____________________________ Email: _____________________________________
Employer: _____________________________ May we contact you at work? Yes [ ] No [ ]
Supervisor/Title: ________________________________________________
What is the best way to contact you during business hours? Work [ ] Home [ ] E-mail [ ] Cell Phone [ ] Other [ ]
Spouse employment: _________________________ # of Children (names and ages): __________________________________________
Is your spouse or roommate okay with you volunteering for this program? [ ] Yes [ ] No
Emergency Contact: ___________________________ Phone: _______________________________
How did you hear about our advocate program? __________________________________________________________________________
Are you volunteering to fulfill an organizational, class, or degree requirement? Yes [ ] No [ ]
When are you available? Weekdays [ ] Evenings [ ] Weekends [ ] (Check all that apply)
Are you bilingual? Yes [ ] No [ ]
If yes, languages : _____________________ Read [ ] Speak [ ] Write [ ]
_____________________ Read [ ] Speak [ ] Write [ ]
_____________________ Read [ ] Speak [ ] Write [ ]
Which opportunities are you interested in? (Check all that apply.)
Accompaniment [ ] Hotline [ ] Educational programs [ ]
Counseling [ ] Administrative [ ] Special Projects/Events [ ]
List previous experience/experience in dealing with people in crisis situations (when/where/how long?): _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Highest grade completed _______ H.S.____________ College (attended/attending) _________________ Graduation Date: _________________
Have you ever been convicted of a law violation (other than a routine traffic violation) or are you currently on deferred adjudication or probation? Yes [ ] No [ ]
If yes, please list offense and when it occurred:
Have you ever been a victim of sexual assault? [ ] Yes [ ] No
If yes, when/where? _______________________________________________________________________________________
Are you currently receiving counseling? [ ] Yes [ ] No
Have you ever had a friend or close relative sexually assaulted? [ ] Yes [ ] No Relationship: ____________________________
Three personal references in Bryan/College Station other than relatives:
Name: __________________________________________ Address: ________________________________________________
Phone: __________________________________________ Occupation: _____________________________________________
Name: __________________________________________ Address: ________________________________________________
Phone: __________________________________________ Occupation: _____________________________________________
Name: __________________________________________ Address: ________________________________________________
Phone: __________________________________________ Occupation: _____________________________________________
I herby certify that all answers given by me on this application are true and correct. I authorize the screening committee of BCRCC, Inc. to write or telephone references that I have listed on this application for the purpose of acquiring reference information from them and to proceed with the screening process. I further release the Rape Crisis Center, Brazos Valley and anyone releasing information to BCRCC, Inc. from any liability based upon such release.
DATED: ______________________________________ SIGNATURE: ______________________________________________________
Volunteer applicants may be subject to a criminal background check
RETURN COMPLETED APPLICATION TO:
Rape Crisis Center, Brazos Valley
Attn: Volunteer Programs
P. O. Box 3082
Bryan, TX 77805
-----------------------------------------------------------------------------------------------------------------------------------
STAFF USE ONLY
Application received: ______________
Called to schedule interview: ________
Interview Date: ___________________