Please answer each of the questions marked below with * as completely as possible. All information will remain confidential.

Have you been a client of BAWAR within the last year?* YesNo
(If you have been a client of BAWAR within the past year, you must wait at least one year after your counseling completion date to apply)

Last Name*

First Name*

Middle Initial

Email*

Primary Phone*
CellHomeWork

Secondary Phone
CellHomeWork

Home Address

Apt. Number

City, State, ZIP*

Birthdate (you must be at least 18 years old to apply)

Are you at least 18 years old?* YesNo

Transportation:* (e.g. car, public transport, cab, etc.)

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Telephone*

Gender

Race/Ethnicity

Any additional identities you would like to share?

Employment Status

Employer

School and Major

Highest Education Attained

Languages Spoken

Please let us know more about you:

Why are you interested in becoming a state-certified sexual assault counselor? Why do you want to work with sexual violence survivors?*

What do you hope to gain from this experience?*

What do you hope to contribute to the training and to the agency?*

What is your personal history with sexual violence? Are you a survivor? If so, where are you in your healing process? How do you think this intensive training on sexual violence issues might affect you?*

Working with these issues can be stressful. How do you take care of yourself and manage stress? What is your support system like?*

What special skills, experience, and interests do you have that you would be willing to share with the agency? (i.e. computer skills, marketing, administrative, fundraising, etc)*

Please list past or present volunteer experiences that you have had.*

What do you anticipate will be the most challenging aspect of being a crisis counselor?*

What do you anticipate being the most rewarding aspect of being a crisis counselor?*

Is there anything that may interfere with you attending all of the training sessions?* (child care, work, etc.)

We have a minimum 9-month volunteer commitment of 36 hours of on-call time each month after you complete the training and receive state certification. Will you be able to fulfill this commitment?*

What else would you like us to know about you?

Please provide the contact information for two references. These can be professional, academic or volunteer references (no friends or family). We do not contact references until after the interview process.*

First Reference Name*

Relationship*

Email*

Reference Phone*

Second Reference Name*

Relationship*

Email*

Reference Phone*