Volunteer Application 2020

(State Certification ~ General Statute 52-146k)

Prospective volunteers must attend all training classes in order to meet State of CT
guidelines to become a Certified Sexual Assault Advocate.

A background check will be completed prior to the beginning of training.

PLEASE include with Application:

**PLEASE include with application:

-A current resume
-Valid driver’s license (FRONT AND BACK)

**Please email, scan or fax your application and supplemental papers (fax
number: 203-878-6450 or email to: [email protected])**

**Upon receiving your application and it being reviewed, you will be contacted to
complete an interview with a member of the office staff**

$50.00 Training Fee is due by the first night of volunteer training:

**Cash or check only(Checks made out to: Rape Crisis Center of Milford)

**Training will take place in the Fall of 2020 in the evening. All classes will run
twice per week (Specific days and dates to be announced).

Please contact Melissa or Stephanie via email or phone with any questions
regarding the application process or training information.
Phone: 203-878-1212
Email: [email protected]
[email protected]
Date of application: _______________

Personal Information:
Full Name (F,MI,L): _____________________________________________________

Full Address: __________________________________________________________

__________________________________________________________

Primary Phone: ________________________

Alternate Phone: ____________________________

Primary Email Address: ________________________________________________

Alternate Email Address: ______________________________________________

D.O.B.: __________________________

Primary Language: _________________

Are you able to speak any other languages? Y____ N____
If yes, please specify. ____________________

Employment Information:
Employer’s Name: ____________________________________________________________
Job Title: ___________________________________________________________
What are the days/hours that you work? _____________________________________
May we contact you at work to follow-up on a case, on-call reminder or an emergency?
YES_______ NO________
Preferred method of contact: Text _________ Call:__________ Email: _________

Emergency Contact:
Who can the staff from RCCM contact in case of an emergency?
Name: _____________________________________
Relationship: ________________________________
Phone: _____________________________________

Are you currently a college student? _____Yes _____No

If so where? ________________________________________________
When will you graduate? ________________
Would want to intern with the Rape Crisis Center of Milford? (Please note that this will
require a separate interview process post-certification). _____________
Can you continue to provide hotline coverage over school breaks/summer? _________
Please complete all of the following questions:

How did you hear about the volunteer position at the Rape Crisis Center of Milford?
_________________________________________________________________
_________________________________________________________________

Why are you currently interested in becoming a volunteer at the Rape Crisis Center of
Milford?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

What are hoping to gain as a volunteer of the Rape Crisis Center of Milford?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Describe any experience or knowledge you have in any of the following areas:
**Prior experience, training or knowledge is not required**
Counseling: _____________________________________________________________
Sexual Assault crisis work: _________________________________________________
Crisis intervention: _______________________________________________________
Support groups: _________________________________________________________
Public speaking: _________________________________________________________
Education: _____________________________________________________________
Medical or legal fields: ____________________________________________________

Please describe any strength’s you feel you have that would enhance your ability to be
an effective sexual assault crisis advocate/counselor.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________

Transportation:
Do you have a valid driver’s license? YES________ NO__________
Driver’s License #: _____________________________State _____________
Do you have reliable transportation (your own car)? _____________

Volunteer Commitment:
All volunteers are expected to provide hotline coverage once certified.
(Please initial each space below).
_____You are willing and able to make a one-year commitment to provide hotline coverage
At least twice a month (Hotline shifts include; holidays, weekdays and weekends)
_____ Are you willing to attend volunteer meetings that are scheduled during the year to
review cases, important information for the center and training opportunities?

Please Check additional areas of interest:

_____ Provide Counseling and Advocacy beyond your hotline coverage, i.e.:
 Arrange one-on-one counseling sessions with client and/or family members
 Accompany victim to meetings with police, court personnel, etc.
 Follow-ups with families
_____ Assist with Community Outreach (Community Education Pre-K-12th grade/campus
Of the University of New Haven
_____ Assist with Fundraising Events (2 that occur within the agency yearly)

**I certify that I have never been arrested, convicted of, pleaded guilty to, or pleaded nolo
contendere, to a state or federal offense.
Yes, I have been arrested, convicted, pleaded guilty, etc. _______________________
No I have never been arrested, convicted, pleaded guilty, etc. ____________________

 Please explain in detail the nature of the arrest, conviction, the disposition date, and the
nature of your sentence.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

**I agree to a background check. I agree to keep all client contacts, of any nature, strictly
confidential. I understand that any breach of client confidentiality is grounds for immediate
dismissal. If accepted into the program, I agree to abide by the rules and regulations of the Rape
Crisis Center of Milford, which will be given to me.
Yes, I agree to a background check __________
No I do not agree to a background check ______

Is there any additional information that you would like us to know about you:
_______________________________________________________________________________
_______________________________________________________________________________

Signature Date
-------------------------------------------------------------------------------------------------------------

Rape Crisis Center of Milford use only:

Date Application Received: ______________________

Date of In-Person Interview:__________________________
RCCM Staff Present in interview? _______________________
Resume Received: _______
License Received: _______

$50.00 Training & Supply Fee Paid: YES________ NO________

Credit Card: _________ Check: ____________

Accept/Non-accept for training: _________________

RCCM Staff Signature: _________________________________Date: ______________

Notes:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________