Name *

First Name

Last Name

Date of Birth *

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DD

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Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have a car? *

Yes

No

Interested subjects *

Visual arts

Writing

Music

Drumming

Dance

Drama

Computer Science

Visual Design

Storytelling

Animation

Others (please specify below)

*

Phone

(###)

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By checking the below boxes, I agree that *

I allow Circle of Friends for Mental Health to use my picture, art, or written material on their website or other public materials to tell the story of Circle of Friends.

I will give 3-4 weeks written and verbal notice before ending my position with Circle of Friends for Mental Health, and at least one week notice before missing a scheduled class. If I cannot make a class due to illness or accident, I will inform the Facility and Circle of Friends for Mental Health.

I affirm that all the facts and agreements set forth in this application are true and complete.

Signature

First Name

Last Name

Criminal Background Check: Waiver Statement It is the policy of Circle of Friends for Mental Health to conduct criminal background checks on all individuals interested in volunteering with the organization. Volunteers in many programs work unsupervised with individuals from our community and occasionally in the school system. For this reason, criminal background checks are necessary to protect the Foundation, the community and the volunteers. The criminal background check will only be used to establish whether or not a potential volunteer has a criminal record within the State of Washington. If a potential volunteer does have a criminal record, s/he will not be placed in certain programs. However, if appropriate, another placement may be considered. This request for a criminal history is performed through the Washington State Patrol and is free of charge to non-profit organizations. All information obtained is and will remain completely confidential. In the case of a criminal record, you will be contacted and given an opportunity to discuss your volunteer placement. If Washington State Patrol reports no criminal record, you will be able to begin your volunteer assignment once you have attended orientation. Have you been convicted of a crime in the State of Washington? *

Yes

No

I have read the above statement and give my permission to the Washington State Patrol to send all criminal record information pertaining to me to: Circle of Friends for Mental Health 4731 15th Ave NE, Ste. 323 Seattle, WA 98105 *

Signature

First Name

Last Name

Date *

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DD

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