Sexual Assault Victim Advocate Application

Step 1 of 2: Submit

Sexual Assault Victim Advocate Application

Prior to completing this application, please ensure that you are able to meet all of the requirements of becoming a Sexual Assault Victim Advocate at The Wellspring.

You must be 18 years of age or older.
You must complete an application and attend a screening interview.
You must undergo a criminal background check.
You must complete 40 hours of sexual assault advocacy training.
You must commit to a minimum of one year of service and to working for at least 3 shifts per month with The Wellspring to remain active and in good standing.

CONTACT INFORMATION

Name Date of Birth

Street Address City State Zip Code Phone Number E-mail Address

AVAILABILITY

Can you Commit to working on a monthly basis for at least 1 year? Yes No

On-Call Schedule: (please check shifts you can generally be available) Monday-Thursday evenings/nights 6 p.m. to 6 a.m. Friday afternoons 12 - 6 p.m. Friday evenings/nights 6 p.m. to 6 a.m. Saturdays 6 a.m. to 6 p.m. Saturday evenings/nights 6 p.m. to 6 a.m. Sundays 6 a.m. to 6 p.m. Sunday evenings/nights 6 p.m. to 6 a.m. Holidays 6 a.m. to 6 p.m.

Do you have access to reliable transportation? Yes No

INTEREST AND SKILLS

How did you hear about The Wellspring Sexual Assault Program? What interests you about this position? Why did you choose to apply for this position? Completed educational degrees/certifications: Major/Minor:

Are you currently a student? Yes No

If yes, what school? Anticipated date of graduation:

Major/Minor:

Is your interest in advocating connected to required course work or community service? Yes No

List any previous training or certifications that might be helpful. Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities.

VOLUNTEER AND WORK EXPERIENCE

Company name, address, phone: Duties assigned: Company name, address, phone: Duties assigned: Company name, address, phone: Duties assigned:

REFERENCES

Name Relationship Phone Number Name Relationship Phone Number Name Relationship Phone Number

PERSON TO NOTIFY IN CASE OF EMERGENCY

Name Street Address City State Home/Cell Phone Work Phone E-mail Address

AGREEMENT AND SIGNATURE
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as an advocate, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I provide consent to contact my listed references.

Name Date

OUR POLICY
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Background checks are required.

Thank you for completing this application form and for your interest in advocating with us.