CHOICES Training Application
Note: To ensure the safety of our clients, volunteers, and the communities we serve, applicants for certain volunteer positions may be asked to consent to a background check in the future. If the position for which you apply requires a background check, we will ask you to complete a separate form to authorize one.
In-kind professionals should be consulting with their employer before attending the CHOICES training to ensure your employer will allow you to attend regular update trainings and to report on your activities during your work schedule.
Applicant Information (please complete BOTH address sections if applicable)
I am applying as a: ______volunteer ______in-kind professional
Applicant name: ______Date: ______
Work Address:
Organization/Agency Name: ______
Address:
City/Town ______State ______Zip code ______
Work Phone: ( ) ______- ______Other phone: ( ) ______- ______
Email address: ______
Home Address: ______
City/Town ______State ______Zip code: ______
Interest in the CHOICES Program
1. How did you learn about the CHOICES? ______
2. Please tell us why you would like to become a CHOICES volunteer? ______
3. Do have a site where you plan to do your counseling? ____Yes ____No
a. If so, have you discussed this with the site? _____Yes ____No
b. Please provide the contact person and locate of the site:
Contact Person______Telephone Number/Email: ______
Name of the location and town:______
------
4. Please indicate the days and times that you are usually available.
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / SundayMorning
Afternoon
Evening
5. Which of the following CHOICES activities are you interested in?
CHOICES Counselor Training ______Group Educations Presentations______
Helping with health fairs______Administrative Support ______
Applicant Demographic Information
The SHIP Program (CHOICES) receives Federal funding from the Administration on Community Living (ACL). ACL requests demographic information on our counselors to ensure we are representing a cross section of Connecticut’s population. We appreciate if you could provide the following demographic information:
Do you speak any languages other than English? Please list language(s): ______
______
Age: ____ Less than 65 years of age ____ 65 Years of Age or Older
Ethnicity: _____Hispanic, Latino Spanish Origin ____Korean
_____White, Non-Hispanic ____Vietnamese
_____Black, African American ____Native Hawaiian
_____American Indian or Alaskan Native ____Guamanian or Chamorro
_____Asian Indian ____Samoan
_____Chinese ____Other Asian
_____Filipino ____Other Pacific Islander
_____Japanese ____Some Other Race-Ethnicity
_____More than one race-ethnicity
Counselor Disability: ____Disabled _____Not Disabled
1. Please tell us about your work experience, including paid and volunteer positions.
If you are currently employed, please list your current job first. Use the remaining spaces to describe other work experiences (paid or volunteer) that relate in any way to the volunteer position, including past history with group presentations. If you need additional space, please attach another sheet of paper.
A. Organization:
City/State: ______
Position/Title: ______Years: ______to ______
Years: ______to ______
Role: _____ Paid employee _____ Volunteer _____ Other
B. Organization:
City/State: ______
Position/Title: ______Years: ______to ______
Type of work:
Role: _____ Paid employee _____ Volunteer _____ Other
C. Organization:
City/State: ______
Position/Title: ______Years: ______to ______
Type of work:
Role: _____ Paid employee _____ Volunteer _____ Other
2. Please describe any skills or experience that would enable you to perform the duties of a CHOICES volunteer.
______
3. Do you have any medical conditions that may affect your ability to function as a CHOICES volunteer, or do you require any special accommodations that the CHOICES coordinator should be aware of?
_____ Yes _____ No If yes, please describe: ______
4. Are you licensed and able to drive an automobile? ______Yes ______No
5. Certain conflicts between personal interests and the interests of the CHOICES program may exist, and could prevent a person from serving as a volunteer. One example is that of a licensed health insurance agent. If you have a business or other personal interest that may create a conflict, please describe it here so we can discuss it fully during your interview.
______
Information
Best method and time to reach you:
Emergency contact person name:
Relationship: ______
Primary phone: ( ) ______- ______Other phone: ) ______- ______
References for Volunteer CHOICES Counselors only (in-kind professionals who will be performing CHOICES counseling during their work day, can skip this section)
Please provide three references, including at least one professional or work reference, that are not related to you and who we may contact to ask about your qualifications (if the reference is a supervisor or co-worker, please note the organization for which she or he works).
A. Name (first, last): ______
Phone number: ( ) ______- ______How long known? ______
Relationship: ______
B. Name (first, last): ______
Phone number: ( ) ______- ______How long known? ______
Relationship: ______
C. Name (first, last): ______
Phone number: ( ) ______- ______How long known? ______
Relationship: ______
Authorization and Certification
I certify that the information I provided in this application is true, complete, and accurate to the best of my knowledge. I also authorize the Department on Aging to contact the references named below with regard to my application to become a CHOICES volunteer. I also authorize the persons referenced to provide information in connection with my application, and release them from any liability in regard to it.
Signature: ______Date: ______
Please complete and return form to:
Patricia Richardson, State Department on Aging, 25 Sigourney Street, Hartford, CT 06106-5041
Or email it to: