Date

Name*

First Middle Last

Previous name (if applicable)

First Middle Last

Email*

Preferred Pronouns

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Day Phone*

Evening Phone

Emergency Contact Information

Name

First Last

Relationship

Phone*

Volunteer Opportunities Desired

Childcare Volunteer
Legal Services Volunteer
Event Volunteer
Outreach Volunteer
Administrative Volunteer

Donation Towards Background Check Fee

I would like to make a donation to cover the cost of my background check ($40). Please make checks payable to Heartly House.

Questionnaire

How did you hear about Heartly House?

Why do you want to volunteer at Heartly House?

Do you have any past volunteer experience?

Yes
No

What experience/training do you have related to the type of volunteer opportunities you selected?

Some volunteer opportunities at Heartly House involve dealing with victims in crisis. What type of crisis intervention training or experience have you had?

Have you or anyone you know had a personal experience with domestic violence, dating violence and/or sexual violence? If yes, please explain.

Yes
No

Experiences

Have you or anyone in your family received services from our agency? Please note services received and last date of service.

Yes
No

Services Received

Do you have any interests or special skills you would like to offer to the Heartly House?

Do you have a reliable means of transportation to and from your volunteer opportunity?

Yes
No

Are you currently employed? If yes, where?

Yes
No

Employment Location

Do you speak, write, and/or understand a language(s) other than English? If yes, what language(s)?

Yes
No

Languages

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Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
						1
2	3	4 The Cottage Series: Heartly House 101 19:00 02/04/2020 - 20:30 02/04/2020	5	6	7	8
9	10	11	12	13	14	15
16	17	18 The Cottage Series: Bystander Intervention 19:00 02/18/2020 - 20:30 02/18/2020	19	20	21	22
23	24	25	26	27	28	29

24-Hour Crisis Hotline: 301-662-8800

Events for February 2020

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Frederick County Human Trafficking Response Team Summit

The Cottage Series: Heartly House 101

The Cottage Series: Bystander Intervention

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Emergency Contact Information

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Events for February 2020

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Calendar of Events

Frederick County Human Trafficking Response Team Summit

The Cottage Series: Heartly House 101

The Cottage Series: Bystander Intervention

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