DESERT REFUGE FOR PEACE OFFICERS & MILITARY PERSONNEL MENTAL HEALTH VOLUNTEER APPLICATION

DESERT REFUGE FOR PEACE OFFICERS & MILITARY PERSONNEL MENTAL HEALTH VOLUNTEER APPLICATION
Date:

MonthDayYear
Date
Name

First NameMiddle NameLast NameSuffix
Gender

MaleFemaleNon Binary
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home

Area CodePhone Number
Work

Area CodePhone Number
Mobile

Area CodePhone Number
School:
Year:
Discipline:

MSWMFTClinical PsychologistChaplainOther
Are you Licensed with the Board of Behavioral Sciences in CA?

YesNo
License #:
List out of state license if applicable:
Certificates/Credentials:
Certificates/Credentials:
Certificates/Credentials:
Certificates/Credentials:
Specialized Training:
Have you ever worked for a law enforcement agency?

YesNo
If “yes,” In what capacity?
Have you served in the military?

YesNo
Rank:
Years of service:
If applicable, list accommodations needed:
Is there a medical condition that we should be aware of in case of an emergency?

YesNo
If yes, explain:
In case of an emergency, person to contact:
Name

First NameLast Name
Relationship:
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
REFERENCES:
Name of Reference 1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship
Name of Reference 2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship
Please indicate area of interest:

Workshop developmentWorkshop presenter in person onlyWorship presenter virtual onlyWorkshop present in person and onlineAnnual Conference presenterGrant writerNon-profit developmentFund RaisingFacilitating Support GroupsOther:
Please indicate area of interest:

I declare under the penalty of perjury that all statements on this form and attachments are true and complete to the best of my knowledge. I understand that false, misleading or incomplete information shall be cause for disqualification.
Volunteer Signature

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Date

MonthDayYear
Date
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DESERT REFUGE FOR PEACE OFFICERS & MILITARY PERSONNEL MENTAL HEALTH VOLUNTEER APPLICATION

REFERENCES: