Facilitator Application

Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Email*
Work Information
Current Employer (if employed)
Occupation
Job Title
Work Phone
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Supervisor's Name
First Last
Previous Employment
Employer
Occupation
Job Title
Supervisor's Name
First Last
What dates were you employed here?
Educational Background*
What educational experiences (college courses, seminars, research, internships, etc) have you had which might contribute to your work with grieving children?*
Describe your own grief experiences (to whatever degree you feel comfortable).*
Describe your experiences (volunteer, professional, or personal) with the age group with which you hope to work, and why you hope to work with this age group.
How did you learn about The Kids' Place?*
What reasons do you have for wanting to become a Facilitator at The Kids' Place?*
What are your expectations for participation in this program? What do you hope to gain from it?*
What do you think you can contribute to The Kids' Place?*
Is there anything likely to keep you from keeping your time commitment to The Kids' Place?*
Which age-groups would you feel most comfortable spending time with?
Which age group would be your first choice?*
Which age group would be your second choice?*
Which age group would be your third choice?*
Support group facilitators at The Kids’ Place will participate in a one hour pre-meeting immediately before each group session and a debriefing post-meeting immediately after group. The total time commitment for evening groups is usually 6:00 to 9:30 p.m., two times per month.
What kind of hobbies or activities do you like to do which you might anticipate doing with participants at The Kids' Place?*
Please identify any physical or medical limitations that may affect your ability to participate in this program.
References
Please print three (3) copies of our References Form (the form will open in a new browser tab), one for each reference. Ask them to complete and return as indicated on the form.
Emergency Contacts
Who should we contact in case of an emergency? (someone who is not at your home number)
Name
First Last
Phone*
Relationship*
Facilitator Agreement & Electronic Signature
I am hereby giving the staff of The Kids’ Place permission to obtain and hold in my confidential file reference information from the parties listed above.

I agree to participate with The Kids’ Place as described on the last page of this application and in the materials describing characteristics, responsibilities, and intent of volunteers at The Kids’ Place.

The information I have provided on this application is complete and true.
By checking this box, I agree to the following...*
- I am hereby giving the staff of The Kids’ Place permission to obtain and hold in my confidential file reference information from the parties listed above.
  
  The information I have provided on this application is complete and true.
  
  Due to the nature of the work at The Kids’ Place, I know that The Kids’ Place reserves the right to accept or reject any potential volunteer.
  
  By submission of these forms, I agree to participate with The Kids’ Place as described on this Facilitator Information Packet which describes characteristics, responsibilities, and intent of volunteers at The Kids’ Place.
Name
First Last

Facilitator Application

Work Information

Previous Employment

References

Emergency Contacts

Facilitator Agreement & Electronic Signature