Circle Leader Application

Circle Leader Application
Name*

First NameLast Name
Date of Application*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Email*
example@example.com
Place of Employment
Mark the box with the preferred method of contact

Call my CellText meEmail meCall/Text my other number

Please mark which and days and time you are available.

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
Morning
Afternoon
Evening

Please list your children (age 18 and under)

	Child's Name	Age	Would attend Children's Program? (yes or no)
Child 1
Child 2
Child 3
Child 4
Child 5

Please anyone else who lives with you and their relation to you.

CODE OF CONDUCT FOR ALL CIRCLES MEETINGS, ACTIVITIES, AND EVENTS

●       I will dedicate myself to supporting all participants and volunteers.

●       I will respect the inherent dignity of every person without regard to their race, ethnicity, creed, age, religion, disability, sexuality, or nationality.

●       I will be honest and strive to be a person of integrity.

●       I will follow Circles’ rules and policies for volunteers.

●       I will not engage in activities which may be seen as a conflict of interest between Circles and myself.

●       I will contribute to a safe environment by not harming others in any way, whether through discrimination, harassment, exploitation, abuse, or neglect.

●       During meetings, I will not be under the influence of illegal drugs or alcohol.

●       If I need to end my commitment to Circles, I will step down considerately and in a way that minimizes disruption to the community.
Initial here:*
STATEMENT OF CONFIDENTIALITY

I agree to ensure the confidentiality and privacy of all who participate including Circle Leaders, Allies, volunteers, and staff. I understand that the fact that an individual is served by Circles must be kept confidential, and at no time will I disclose personal information that is shared at Circles meetings.

I understand that Circles maintains a strict policy on the confidentiality of my records. All information I share or which Circles becomes aware of through my involvement will remain confidential and will not be shared with anyone outside of Circles unless I have given my written permission.

I understand that there are some situations where this confidentiality policy becomes void and staff are required by law to release information. These circumstances include: (1) If Circles becomes aware that I may be a danger to myself or others; (2) If Circles become aware of an adult, elder, or child abuse situation taking place; (3) If Circles is under court order to share information.
Initial here:*
MEDIA RELEASE - ADULT

Your Circles chapter, legally named Circles Essex, together with Circles USA, (jointly referred to as “Circles”) sometimes use photos and videos of participants and volunteers in social media and promotional materials. Please read the below media release and sign if you agree to these terms.

I grant permission to Circles to use my image (whether photograph or video) in its media publications including emails, brochures, publications, presentations, videos, social media, and websites. I waive any and all rights to inspect or approve of the photographs or media prior to their use. I waive any rights to royalties or compensation arising from use of these images.

***Declining does NOT bar you from participating in the program***
Type a question*

Yes for me and my childrenYes for me not my childrenNo
Should be Empty:

Circle Leader Application

2024 Federal Poverty Line