Crisis Line of Central Virginia
Volunteer Application

Volunteer Opportunities

Are you interested in serving as (check which apply):
Crisis Line/Teen Talk  telephone helper______
Sexual Assault Response Program Companion______
or both Crisis Line phone helper and Sexual Assault Response Program Companion_____



Name_________________________________________________
    First                              Middle                   Last

Home Address _____________________________________________Zip_____________

Home Phone __________________________________Birthday _____________________

Occupation________________________________________________________________

Name of  Business___________________________________Business Phone__________

Business Address___________________________________________________________

Supervisor’s Name_______________________How long have you worked there?_______

How long have you lived in this geographic area ?________________________________

Education ( write last level completed ):

High School___________College____________

Special Training_______________________________________________________

List any organization which you are a member/volunteer:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________



List any prior experience in dealing with crisis situations:
______________________________________________________________________________

______________________________________________________________________________
Have you ever  been convicted of a felony or misdemeanor?______________If yes, please explain the circumstances.
______________________________________________________________________________

______________________________________________________________________________


Which days of the week are you able and willing to work?_______________________________

What are the approximate number of hours per month you could volunteer?_________________

Do you have reliable transportation?_____________________

Please give two references of individuals ( non-related ) whom we can contact. List names, relationship, addresses and
telephone numbers. You may also supply a resume in addition to the below name references.

1)____________________________________________________________________________

______________________________________________________________________________

2)____________________________________________________________________________

______________________________________________________________________________

Why do you want to volunteer for the Crisis Line agency ?  
_________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Where did you find out about Crisis Line?_________________

Due to the sensitive nature of the services we offer, it is necessary to have a background check of all applicants. This
will include references and a police background check. If you are interested in pursing this application, please sign and
date the following Release of Information statement.

I understand that the training program staff will accept, without prejudice, resignations from the training program at the
conclusion of the first session (orientation), but will expect trainees to fully participate in all training sessions thereafter.

I also understand that, should I pass the training course and be accepted as a volunteer, I will make a commitment to
serve Crisis Line as a volunteer for a minimum of one year.

Crisis Line of Central Virginia, Inc. reserves the right to discontinue the relationship with volunteers or potential
volunteers if the executive director determines it to be in the best interest of the agency.

Signature________________________________Date______________________________


Please return to:

Crisis Line of Central Virginia, Inc
P.O. Box 3074
Lynchburg, VA 24503