CENTER FOR A NON VIOLENT COMMUNITY

P.O. Box 1147 ~ 19900 Cedar Rd. North, Sonora, CA 95370

Office 588-9305 x101 ~ Fax: 588-9272 ~ Crisis Line 533-3401
reception@mountainwomen.org

Volunteer Application
This application is confidential and will be read only by CNVC staff.
Thank you for your interest in the CNVC Volunteer Program. We invite prospective volunteers from diverse back-
grounds and experience to assist us in providing service and support to individuals who are victims of domestic violence
and sexual assault in our community.

Name:_____________________________________________________ Date of birth: _____________________

Address: ____________________________________________________________________________________
City, State, Zip: ______________________________________________________________________________
Daytime Phone # ( ) _________- ______________ Evening Phone # ( ) ________-______________
E-Mail Address: _______________________________________________________________________

Note: If you need more room for your answers, please feel free to attach additional pages

 Tell us why you are interested in volunteering at CNVC.

 What skills and talents do you have that you would use as a volunteer for CNVC?

 Are you interested in becoming a certified domestic violence and sexual assault peer counselor?

 Describe some of your life experiences, education and/or work experiences that would be helpful as a
domestic violence and sexual assault peer counselor.

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  Have you been involved with any other volunteer organization(s)? If so, list the organization(s),
include the dates you volunteered. Please give a brief description of the duties that you have preformed
for these organizations.

 Are you a survivor of sexual assault or child abuse? If so, when did the assault or abuse happen?
Did you seek counseling, or other support?

 Are you a survivor of domestic violence or a child witness to domestic violence? If so, when did the
abuse happen? Did you seek counseling, or other support services?

 Have you ever engaged in any form of sexual abuse, harassment, domestic violence, or assault?

 How many hours a week are you available to volunteer? ______________________________

 If you choose to become a certified peer counselor and participate in the 60 hour training, can you commit to
attending all of the training sessions ?

Yes_______ No __________ (May include weekend sessions)

I can attend training (circle all that apply) 8am-6pm 6pm-9pm Weekends
Please add any other information that may help us with our training schedule:

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  How did you learn about our Volunteer Program?
___Flyer ___Friend ___CNVC Presentation ___CNVC Brochure Other________________

 Can you commit to volunteering for a minimum of 6 months? Yes __________ No _________

 Can you attend monthly volunteer in-service meetings (usually 1 evening a month—currently Tuesdays)?
Yes______ No _______ Would you be able to attend if it were a different evening (specify)_________

 Is there anything else you would like to tell us about yourself?

Please list two references:

1) Name_________________________________________ Relationship to applicant ___________________

Address _______________________________________________________________________________

City:____________________________________State___________________ Zip Code:_____________

Phone # ( ) __________ - _______________

2) Name_________________________________________ Relationship to applicant ___________________

Address _______________________________________________________________________________

City:____________________________________State___________________ Zip Code:_____________

Phone # ( ) __________ - _______________

---------------------------------------------------------------------------------------------------------------------------

Please print name: ____________________________________________________________________

Signature: __________________________________________________________________________

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