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?*\