Last Name*

First Name*

Middle Initial

Your Email*

Primary Phone

Secondary Phone

Mailing Address

Apt. Number

City, State, ZIP


Drivers License

License State


WhiteBlack/African AmericanLatina(o)AsianHawaiian/Pacific IslanderNative American/AlaskanOther

Employment Status


School and Major

Highest Education Attained

Languages Spoken

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Telephone*

Please answer each of the questions below as completely as possible. All information will remain confidential.

Why are you interested in becoming a state-certified rape crisis counselor? Why do you want to work with sexual assault survivors?*

What do you hope to gain from this experience?*

What do you hope to contribute to the training and to the agency?*

What is your personal history with sexual assault? Are you a survivor? If so, where are you in your healing process? How do you think this intensive training on sexual assault issues might affect you?*

Working with these issues can be stressful. How do you take care of yourself and manage stress? What is your support system like?*

What special skills, experience, and interests do you have that you would be willing to share with the agency? (i.e. computer skills, marketing, administrative, fundraising, etc)*

Please list past or present volunteer experiences that you have had.*

What do you anticipate will be the most challenging aspect of being a crisis counselor?*

What do you anticipate being the most rewarding aspect of being a crisis counselor?*

Is there anything that may interfere with you attending all of the training sessions?* (child care, work, etc.)

We have a minimum 9-month volunteer commitment of 36 hours of on-call time each month after you complete the training and are state-certified. Will you be able to fulfill this commitment?*

What else would you like us to know about you?*\