Circles Ally Application Name * First Name Last Name Email * Phone Number * Best number to reach you: Address Address 1 Address 2 City State/Province Zip/Postal Code Country Employer & Job Title * Best Times to Reach You * Primary Criteria Please check all that apply to you: * Currently live at or above 200% of the Federal Poverty Guidelines (see below) At least 21 years old Able to attend weekly classes or meetings Committed to learning and applying new ideas Willing to build intentional relationships across class and cultural lines Background Information How did you learn about Circles Ashland? * Summarize skills, qualifications, and or training you have acquired from employment, education, life experience, hobbies or sports that you would like to share with others. * List community, social, or faith-based groups and organizations that are involved with. * What would you like a Circle Leader to know about you before you are being matched? * How would you describe your conflict management style? * What are some strengths that you bring to the table? * What are some weaknesses that you bring to the table? * Additional comments? Have you ever been convicted of a felony? * A felony or other conviction will not automatically exclude you from participating in Circles Ashland. Background Checks are a requirement because children may be present during Circles meetings. Children will be supervised by their parents during meals and under the care of screened childcare providers while Circle Leaders are in meetings. Yes No Currently, are there any pending court cases in which you are involved? Yes No Are there any active warrants outstanding (to the best of your knowledge)? Yes No Person to Notify in Case of Emergency Emergency Contact * First Name Last Name Relationship * Phone Number * Agreement and Confidentiality Statement As a participant of Circles I understand that I must ensure the confidentiality and privacy of all those who participate including Allies, volunteers, and staff. I further understand that the fact an individual is served by Circles must be kept private and confidential, and at no time shall I disclose personal information that is shared in Circles. Name * First Name Last Name Thank you!
