The Arkansas Crisis Center welcomes the participation of volunteers who support our mission! Please return the completed form directly to the center by fax: 479-756-2338; or regular mail: 614 E. Emma,
Suite 213, Springdale, AR 72764. Your input will help us select the best possible candidates for this life-
changing work! Information gathered on this form will be kept confidential within the ACC.
To be completed by the APPLICANT:
Name of Applicant: ______________________________________Date__________________
Address:___________________________________City/St/Zip:__________________________________
Primary Phone: ______________________________Email Address______________________________
To Be Completed by the PERSON PROVIDING REFERENCE: (2 pages)
 Yes  No Are you related to this applicant by birth or by marriage? (If yes, you are not eligible to serve as a reference.
Please return form to applicant.)
Your Name:_______________________________ Primary Phone________________________________
E-mail Address: __________________________Best Time to Contact (if we have questions):__________
0 1 2 3 4 5
Shows good judgment in difficult situations.
Is able to remain calm in times of high stress.
Shows genuine care and empathy toward persons in need.
Is naturally curious, inquisitive, a quick learner.
Is a fast learner with technology (phones and computers).
Is accepting of supervision, always open to improving.
Follows through on commitments they have made.
Is mentally and emotionally healthy in regards to the crises that
have occurred in his/her own life.
Is open-minded; can work with diverse issues and people in a non-judgmental manner.
Can think well on his/her feet while following established policies and protocols.
Can be trusted to keep important information confidential.
Is well-grounded and practices good self-care.

Page 2
Reference for (name of Applicant): ________________________By:_____________________
List any special skills of qualities that you think will make this applicant a good volunteer:
Describe any concerns that you have about this applicant working with persons in crisis or any limitations you foresee in their ability to volunteer by telephone or computer:
Finally, please elaborate on any recent events or on-going personal situations or commitments which might mean that volunteering at another time would be a better choice for this applicant:
Signature: ___________________________________________ Date: _________________________
Thank you for your honest assessment of this applicant. If you prefer to answer confidentially by
phone, please call the Program Manager at our business line 479-756-1995.