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Volunteer application

Interested in becoming a Break the Cycle's volunteer? The first step is to complete and print out our volunteer application.

The information on this form will help us find the most satisfying and appropriate volunteer position within Break the Cycle for you. After you submit the application, Break the Cycle's volunteer coordinator will contact you to arrange your attendance at an upcoming new volunteer orientation.

We appreciate your effort in completing this application.

Basic information

Name:

Address:

City:

State:

Zip Code:

Home phone:

Work phone:

Cell/other number:

Fax:

Email:

Birthday:

Gender:

F M


Education, employment and volunteer experience

High school:

College/major:

Grad school/degree:

Occupation:

Are you presently employed?

Yes

No

Position:

Employer's name:

Community service/volunteer experience:

Skills and interests
Language skills: Are you fluent in a language other than English? Yes No

Please list skills or experience outside your professional area (e.g. graphic design, art, computers, etc.):

Do you have any disabilities which might prevent you from participating in certain activities?

Are there any volunteer opportunities that you are particularly interested in participating in?

How did you hear about Break the Cycle?

Why do you want to volunteer with us?

Break the Cycle is able to provide its services because of the generosity of others. Please indicate if you know of someone who might be willing to donate funds, services or supplies:

Commitment
I would like to volunteer hours per (week, month, etc.)
Specify days and/or times available

Emergency contact information
Please provide us with the name and telephone numbers of a person to contact in the event of an emergency:
Name: Relationship:
Home phone: Work phone:

References
Please list as references three people who have known you for at least one year, and who can vouch for your character, reputation, ethics, experience, and potential as a volunteer for Break the Cycle. Please include at least one work or school reference.

1) Name: Daytime Phone:
Address: Relationship:

2) Name: Daytime Phone:
Address: Relationship:

3) Name: Daytime Phone:
Address: Relationship:

Background information
Have you ever been convicted of a crime? Yes No

If yes, please explain:

Are you a licensed attorney? Yes No

If yes, please provide:
State: Bar Number:

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