Circles Ally Application – Circles Ashland

Contact Information
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Place of Employment
Work Phone
Email*
Preferred Method of Contact

Family Information
Child Name(s), Age(s)
Background Information
1) Summarize skills, qualifications, and or training you have acquired from employment, education, life experience or through activities, including hobbies or sports. Passions and talents you would like to share with others.
2) List community/social/faith-based groups and organizations you are involved with that referred you or that you may be able to share with a participant.
How did you hear about Circles?
What about being an Ally is of interest to you?
What would you like a Circle Leader to know about you before being matched?
What behaviors do you find most frustrating in people?
I am really good at:
I am not so good at:

Have you ever been convicted of a felony?*
- Yes
- No
Currently have pending court cases?*
- Yes
- No
Any active warrants?*
- Yes
- No
If yes, please explain:
(Note: Background Checks will be a requirement for participating in any activities where children may be present)
Person to Notify in Case of Emergency
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone

Agreement and Confidentiality Statement
As a participant of Circles I understand that I must ensure the confidentiality and privacy of all those who participate including Allies, volunteers, and staff. I further understand that the fact an individual is served by Circles must be kept private and confidential, and at no time shall I disclose personal information that is shared in Circles.
Name*
First Last
Signature*
Date*
MM
DD
YYYY
Thank you for completing this application form and for your interest in participating with Circles!

Contact Information