Professional Development Workshop Registration Form

DOMESTIC VIOLENCE TRAINING APPLICATION

This information will be kept strictly confidential. Please type or print clearly.
What are you applying for?

Professional Development - (Education only) 40hr training mandated by State of California (includes volunteer training hrs) Community Service Only (No Education/No Domestic Violence Certification) Other (please specify)
Please specify if other
Full Name *

Prefix First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mobile Number *

Area Code Phone Number
Work Number

Area Code Phone Number
E-mail *
Preferred Contact Method

Mobile Phone Work Phone Email
Current Employer
Occupation
Emergency Contact Name
Emergency Contact Phone
Have you ever been convicted of a FELONY crime within the last 7 years?

Yes (please complete below question) No
If yes, please specify date, place, and charge:
How did you learn of our Volunteer Program?
What is the last grade of school you completed?
Languages Spoken:
Please answer the following questions:
Which of your skills or experiences do you think will be beneficial to our program?
What do you expect to learn from our training?
What is your experience working with diverse populations or people in crisis situations?
How do you take care of yourself when doing emotionally challenging work?
Please list three (3) work-related references:
Reference #1 Name

First Name Last Name
Reference #1 Phone Number

Area Code Phone Number
Reference #2 Name

First Name Last Name
Reference #2 Phone Number

Area Code Phone Number
Reference #3 Name

First Name Last Name
Reference #3 Phone Number

Area Code Phone Number
Please check the volunteer opportunities that interest you:

Direct Services (Hotline, Shelter, Other, etc) Shelter Support Children’s Program Teen Violence Prevention Program Administrative/Fund Development Special Events
By clicking SUBMIT, I certify that the information provided on this application is true and correct.

I further understand that if I am interested in Domestic Violence Certification, I must attend all education sessions and complete volunteer training hours with a minimum of 60 hours over a 9 month commitment.
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DOMESTIC VIOLENCE TRAINING APPLICATION

Please answer the following questions:

Please list three (3) work-related references:

By clicking SUBMIT, I certify that the information provided on this application is true and correct.