Circles Ally Application

Circles Volunteer Application
Full Name

First NameLast Name
Today's Date

MonthDayYear
Date
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone
Please enter a valid phone number.
Other number with area code
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Volunteer Interest
Preferred Method of Contact (choose all that apply)

Call to Cell PhoneTextEmailCall to Other Number

Available Dates

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

Background checks are required for participation in any activities where children may be present.
Have you ever been convicted of a felony

YesNo
If yes, please explain:
Do you currently have a court case pending?

YesNo
If yes, please explain:
Do you have any active warrants?

YesNo
If yes, please explain:

Emergency contact name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Circles chapter, legally named Circles Essex, together with Circles USA, (jointly referred to as “Circles”) request that you agree to the following Code of Conduct and Statement of Confidentiality. Please read them and sign below to indicate your agreement with these statements.

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.
Accepted and Agree Upon (please input initials):
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/volunteering in the program***
Accept:

Yes myself and familyYes myself onlyNo
Should be Empty:

Circles Volunteer Application

Background checks are required for participation in any activities where children may be present.