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 _______________________
Work Phone: (
State _____________
) __________- ________________
Zip code ________________
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
Sunday
Morning
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:
patricia.richardson@ct.org