Newsletter – Crisis Center of Central NH | 1-866-841-6229

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Street Address City State ZIP Code
- Availability*
  - Days (7a-7p)
  - Evenings (7p-7a)
  - Weekends
- What type of involvement are you interested in?*
  - Crisis Line
  - Hospital Advocacy
  - Shelter Advocacy & Transportation
  - Court Advocacy
  - Outreach
  - Office Time
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- Have you ever been convicted of any crime:*
  - Yes
  - No
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- Have you ever been reprimanded, disciplined in any way or dismissed as an employee or volunteer because of:*
  - Sexual Misconduct
  - Violent Conduct
  - None
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- Do you have a problem with drugs and/or alcohol?*
  - Yes
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- Have you ever had a temporary or final domestic violence protective order against you?*
  - Yes
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- Date Range*
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- Current Employer
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- Previous Employer
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Please list 3 personal references that you have known for at least 2 years and that are not related to you:
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- I authorize the people and employees and officers of the places I have mentioned above to provide The Crisis Center of Central New Hampshire any information requested by the Center that may be required to arrive at a decision about my application to work as a volunteer.
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