Administrative Offices

601 S Carlin Springs Road

Arlington, VA 22204

Please email as attachment to

Volunteer Crisis Worker Application

Date: / Are you 21 years of age or older?
Yes No
Volunteer Hotline Crisis Workers must be at least 21 years of age or older.
First Name MI / Last Name
Street Address/Apt #
City / State/Zip
Telephone (please check preferred contact number)
Home / Work / Cell
Email Address
EDUCATIONAL BACKGROUND (attach résumé if possible)
Skills and Qualifications
What special interests, skills, or hobbies do you bring to the organization?
Are there any special projects on which you would like to work in addition to hotline volunteering?
PRIOR VOLUNTEER EXPERIENCE
Organization / Duties / Dates of Service
Please describe your reasons for wanting to be a PRS CrisisLink Hotline/Textline Volunteer. (Minimum 300 words, attach separate document if needed)
Where did you hear about PRS CrisisLink? Please be specific.
When are you available to interview with PRS CrisisLink?
Weekday Mornings Weekday Evenings Weekend Mornings Weekend Afternoons
Training and volunteering at PRS CrisisLink can be stressful. We have a responsibility to ensure that our volunteers will not be adversely affected by the experience. If you are currently in therapy, we would like to have your permission to speak with your therapist regarding this volunteer opportunity. (We consider therapy a positive activity). You will need to also sign your therapist’s authorization form to give him/her permission to speak with us. If your therapist does not have an authorization form, we can provide one for you upon request. (Available at the interview session).
Are you currently in therapy? Yes No
Will you allow PRS CrisisLink to contact your therapist? Yes No
If YES, please sign below authorizing PRS CrisisLink to communicate with your therapist.
Signature ______
Therapist Name ______Phone ______
(Please print)
Other Information
1.  Except for records that have been expunged, have you been arrested and/ or convicted of a crime?
Yes No
If yes, please list all convictions and explain:
2.  Are you currently subject to pending charges for any offense?
Yes No
If yes, please list all cases and explain:
3.  Do you have access to Reliable Transportation?
Yes No

Can you commit to 150 hours/one year (after training) of volunteer work with PRS CrisisLink?

Yes No

Volunteer Activity Preference (Please choose one.)

I am applying to volunteer on the crisis hotline. [Must Complete Hotline Shift Preference Section]

I am applying to volunteer on the crisis textline. [Must Complete Textline Shift Preference Section]

Training Class Availability

Please let us know your availability for the Summer 2015 Hotline or Textline Training Class Schedule. (Your response should be based on the Training Schedule provided for your volunteer activity preference.)

I am available for all of the training class dates listed on the Summer 2015 Training Schedule

I have a conflict with one or more of the training class dates listed on the Summer 2015 Training Schedule

Describe Conflict:______

Hotline Shift Preference:
Below on the hotline schedule needs chart (see page 4 if you are interested in the textline), the shifts that are colored in blue are the current needs of the hotline. Each shift is three hours long.

Shift Preference 1: Day of week ______Time Slot______
Shift Preference 2: Day of week ______Time Slot______
Shift Preference 3: Day of week ______Time Slot______

Textline Shift Preference:

Below on the textline schedule needs chart the shifts that are colored in purple are the current needs of the texting program. Please indicate which shifts you are applying for in order of preference below:

Shift Preference 1: Day of week ______Time Slot______

Shift Preference 2: Day of week ______Time Slot______

Shift Preference 3: Day of week ______Time Slot______

Additional Comments for Hotline or Textline Shift Preferences (if any):

Have you previously completed ASIST Training? Yes No

If Yes, Date of Completion: ______

(Please attach copy of certificate if completed previously)

Have you previously completed Mental Health First Aid? Yes No

If Yes, Date of Completion: ______

(Please attach copy of certificate if completed previously)

EMERGENCY CONTACT INFORMATION
Name / Phone

I certify that the answers given herein are true and complete to the best of my knowledge. This includes the attached reference form. I authorize PRS, INC. to thoroughly investigate my background, references, educational record, employment record and other matters related to my suitability as a volunteer. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations contacted by PRS, INC. to provide any relevant information regarding my school transcript, current and/or previous employment and I release all persons, schools and employers of any and all claims for providing such information. I understand that misrepresentation or omission of facts may result in rejection of this application.

Signature

REFERENCES

We will contact you before checking your references. A minimum of 2 completed references is required to complete application screening.

A. Please provide a supervisory reference. This reference must currently be or have previously been responsible for evaluating your work performance. (if applicable)
Name / Relationship / Telephone Number(s) and Email Addresses:
B. Please provide a reference from a prior volunteer experience (if applicable).
Name / Relationship / Telephone Number(s) and Email Addresses:
C. Please provide a professional reference (no personal friends or family members).
Name / Relationship / Telephone Number(s) and Email Addresses:

Page 5 of 6

Last Updated 5/8/15 KC