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  • Circle Leader Application

  • Client Information

  • Employment Information

  • Are you in School?
  • Are you Employed?
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  • Best Time To Contact (Check all that apply)

  • Mornings
  • Afternoons
  • Evenings

  • Primary Criteria (Check all that apply)

  • Select your level of Federal Poverty Guidelines ( Refer to Diagram below )
  • Lives in Burke county
  • Housing Status
  • Primary Language
  • Able to attend weekly meetings on Thursdays from 5:30 to 7:30 pm
  • Motivated (interested in learning and applying new ideas)
  • Willing to build intentional relationships across class and cultural lines
  • Family supports and encourages involvement in Circles program
  • If history of alcohol or other addiction, has been in recovery for at least the past 6 months

  • Family Information (for all members in your household)

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  • Background Information

  • Additional Information

  • If yes to any of these questions, please explain below:

    (Background Checks will be a requirement for participating in any activities where children may be present)

    *Go to the courthouse and request a free non-certified copy of your background check

  • Person to Notify in Case of Emergency

  • Agreement and Confidentiality Statement

  • As a participant of Burke County Circles I understand that I must ensure the confidentially and privacy of all who participate including allies, volunteers and staff.

  • Burke County Circles Staff Use Only

  • Client Signature                                                                                 Date                                                       

     

    Staff Signature                                                                                  Date                                                        

  • Thank you for completing this application form and for your interest in Participating with Circles!

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