First Name:*

Last Name:*

Address:*

City:*

State:* – Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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:*

Phone:*

Alt. Phone:

Email:*

Emergency Contact:*

Phone:*

Your Employer:

Your Position:

Are you a parent or family member of a child or children with a mental, emotional or behavioral disorder?

– Yes No

Where did you hear about IDFFCMH?*

Have you been convicted of a felony? – Yes No

Please explain:

Please list the days, times, and # of hours per week you are available to volunteer:*

Why are you interested in volunteering for IDFFCMH?*

Please tell us how your skills, experience or knowledge related to children's mental health can help you in this volunteer position:*

In what areas are you interested in volunteering? (for example: computer, telephone, advocacy, fundraising, etc.)?*

To help us get to know you better, please assess your ability and/or experience in the following:*

Ability to provide education and information to families: 1 (Little) 2 3 4 5 (Great)

Willingness to advocate in a variety of settings: 1 (Little) 2 3 4 5 (Great)

Ability to participate and facilitate trainings: 1 (Little) 2 3 4 5 (Great)

Willingness to be a representative/spokesperson for IFFCMH: 1 (Little) 2 3 4 5 (Great)

Knowledge of children's mental health services: 1 (Little) 2 3 4 5 (Great)

Knowledge of educational rights for children with special needs 1 (Little) 2 3 4 5 (Great)

Ability to maintain confidentiality of families served 1 (Little) 2 3 4 5 (Great)

Ability to participate and facilitate support groups 1 (Little) 2 3 4 5 (Great)

What training, resources or support do you anticipate needing to do this volunteer work?*

Please provide two personal or professional references:*

Name:

Phone:

Relationship:

Second reference:*

Name:

Phone:

Relationship:

We are establishing a support network for families of children with emotional, behavioral or mental disorders in your area. Would you like to be part of this network?*

– Yes No

Are you willing to have your name and contact information released to other families?*

– Yes No

  I understand that the IFFCMH conducts background checks on all volunteers. I hereby attest that the above information is true to the best of my knowledge.