Peer-Facilitated Group Host & Co-Host

YOUR BASIC INFORMATION
Name *
Name
Address *
Address
We require your address in order to be able to do a background check.
Phone *
Phone
Best Way to Reach Me
Date of Birth *
Date of Birth
These are the pronouns you like to be referred to as.
EMERGENCY CONTACT INFORMATION
Emergency Contact's Name *
Emergency Contact's Name
Emergency Contact's Phone Number *
Emergency Contact's Phone Number
VOLUNTEER INFORMATION
Please indicate your available hours to volunteer (days and times).
For example: I am an art therapist who would love to teach a monthly art class. Additionally, I can speak Spanish fluently.
Would you like to be a Host and/or Co-Host?
The Host will "lead" and the Co-Host will be assisting the Co-Host.
If so, please write their name below.