First Name:   Last Name:   Middle Initial:

Mailing Address:   City:  

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  Zip Code:

Date of Birth (MM/DD/YY): / /

Home Phone: ( ) -    Email Address:

Employer:   Work Telephone: ( ) -  

May we contact you at work? Yes    No

Race: (please check all that apply)
Caucasian    African American    Asian    Polynesian or Hawaiian or Pacific Islander
American Indian or Alaskan Native    Other:


Ethnicity: select Hispanic/Latino Non-Hispanic/Non-Latino

Religion: select LDS/Mormon Catholic Methodist Unitarian Other Christian Affiliate Jewish Buddhist Muslim Hindu None    Other:




REFERENCES: List three references not related to you who could verify the skills needed to volunteer
for the Rape Recovery Center. Note: The completion of this section is required for processing.


Name:   Address:

Home Tel: ( ) -   Work Tel: ( ) -

Name:   Address:

Home Tel: ( ) -   Work Tel: ( ) -

Name:   Address:

Home Tel: ( ) -   Work Tel: ( ) -

Have you ever been convicted of a criminal offense (traffic violations excluded?) If so, please explain.

Yes    No






Have you ever worked or volunteered at a Rape Crisis Center?

Yes    No    If so, where?

May we contact them? Yes    No




Please list and briefly describe past and present experience with volunteer/service activities.






Are you willing to commit to a min. of 20 hours per month to the Rape Recovery Center?

Yes    No




Would you be able to provide services in any other language? Yes    No

If so, what language?




How did you hear about the Rape Recovery Center?






Why are you interested in volunteering for the Rape Recovery Center?






PLEASE READ the following and explain how you would
react to the callers in the hypothetical situations below.

A rape victim wanting an abortion:




A rape victim who happens to be male or gay:




A rape victim with a reportedly “promiscuous background”:




A sex offender:




A victim who refuses to go to the police even though the
offender is a known rapist and will probably rape again:




An obscene phone caller wanting to masturbate to your voice:




A caller who wants to ventilate feelings about rape and
makes the statement, “women only get raped if they ask for it.”:

* By submitting this form via email, you certify that the above information is correct.