MOTLRT_Volunteer Application

Mid-Ohio Traumatic Loss Response Team Volunteer Application
I am interested in serving:
Date

MonthDayYear
Date
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Occupation
Driver's License Number
Emergency Contact
Name

First NameLast Name
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone (work/home/etc)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Volunteer Interest and Questions
Please check the area of interest:
What interests you about this type of Volunteer Advocacy?
If applicable, please describe your personal experience with suicide and/or traumatic loss:
Survivor of a Type a label loss
Month/Year of loss:
Relationship to deceased:
Deceased name:First Name   Last Name
Deceased date of death:Date
Reference

Please list one non-relative reference we may contact to understand your experience, talents, and character.
Name

First NameLast Name
Relationship
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Cornerstone of Hope and the volunteer applicant acknowledge that the training class is a time of exploration, and attendance does not guarantee a volunteer placement. By signing this document, you agree to complete a state and national background check as part of the application process.
Signature
Date

MonthDayYear
Date
Should be Empty:

Mid-Ohio Traumatic Loss Response Team Volunteer Application

Personal Information

Emergency Contact

Volunteer Interest and Questions

Reference