Name
*
First Name
Last Name
Email
*
Age
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
May we leave a message at the above phone number?
Preferred Method of Contact
Best Times to Reach You
Place of Employment
Weekday mornings
Weekday afternoons
Weekday evenings
Weekend Mornings
Weekend Afternoons
Weekend evenings
Please check all that apply:
Summarize skills, qualifications, and or training you have acquired from employment, education, life experience, or through activities, including hobbies or sports. Passions and talents you would like to share with others:
List community/social/faith-based groups and organizations you are involved with that referred you or that you may be able to share with a participant:
Please tell us where you heard about Circles.
What would you like a Circle Leader to know about you before you are being matched?
What behaviors do you find most frustrating in people?
I am really good at:
I am not so good at:
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.
Currently, are there any pending court cases in which you are involved?
Are there any active warrants outstanding (to the best of your knowledge)?
Emergency Contact
First Name
Last Name
Relationship
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (Best contact number)
Please add any additional comments:
Name
First Name
Last Name
Date
MM
DD
YYYY
