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