Certified Rape Crisis Counselor Application

Certified Rape Crisis Counselor Application

Only authorized PPNCNY Sexual Assault Services staff have access to completed applications. If you feel uncomfortable about answering any specific questions in writing, please email shelli.lavoie@ppncny.org
General Information You may save this application for later completion by clicking "save and complete" at the bottom of the page
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
ex. (888) 123-4567Format: (000) 000-0000.
Email*
example@example.com
When can you start? Date
YesNo
YesNo
Please list your college, year, and major
OngoingTemporaryUnknown/not listedOther
ClintonFranklinEssex
YesNo
Please give dates and details of each
References Please list three references, preferably two professional (employer, academic professor, etc.) and one personal (not a relative). If you do not have a professional reference, please list personal references.
Name

First NameLast Name
ProfessionalPersonal
Organization & Position
Dates of Employment/Length of Relationship
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
ProfessionalPersonal
Organization & Position
Dates of Employment/Length of Relationship
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
ProfessionalPersonal
Organization & Position
Dates of Employment/Length of Relationship
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Experience Please tell us about any present or prior work or volunteer experience. Experience is helpful, but is not required to be accepted as a volunteer with our program.
Employer 1
Dates Employed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Position
Supervisor
Description of Duties
Reason for Leaving
Employer 2
Dates employed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Position
Supervisor
Description of Duties
Reason for Leaving

What is your availability? (check as many as you would like)*

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evening

How many days/hours a week are you able to commit to being on the hotline?
Please tell us a little about yourself, including what strengths and skills may be utilized as a volunteer at PPNCNY Sexual Assault Services.
Please tell us about any prior experience you many have, serving as a volunteer. What impact did it have on you?
Please tell us anything else you think we should know about you!
By signing this application, I certify that all of the information that I provide on this application and in any interview will be true, complete and accurate. I understand that if I am selected as a volunteer and any such information is later found to be false or misleading in any respect, I will be dismissed. I further understand that PPNCNY may contact my previous employers and I authorize those employers to disclose to PPNCNY all records and other information pertinent to my employment with them. I release my previous employers from any liability as a result of their disclosure of information about me to PPNCNY.
Initial and Date*
It is the policy of PPNCNY to provide equal employment opportunities and non-discrimination practices. PPNCNY will advertise for, recruit, and employ qualified personnel and recruit qualified volunteers, without regard to age, race, creed, religion, color, gender, gender identity or expression, sexual orientation, national origin, disability, veteran status, marital status, or genetic information. No employee or volunteer will be subjected to discrimination in employment conditions or volunteer working practices of the Agency. The CEO is charged with the responsibility of ensuring the Agency's compliance with this policy.
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