Speaker Volunteer Application Name* First Last Date MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone*Email* Employer (if applicable) Employer's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code In Case of Emergency PhoneHow did you hear about embrella? Why would you like to volunteer at embrella?Complete this section if you are or were a New Jersey licensed resource parentWhat is the status of your home with DCP&P?* Open Closed License Number Approximately how long have you been a licensed resource parent in New Jersey?* Type of Home* Kinship Provider Resource Family Adoptive Home I provide or have provided care to children with the following characteristics (check all that apply)* Infants (0-2 Years) Early childhood (3-5 Years) Childhood (6-11 Years) Early Adolescents (12-15 Years) Late Adolescents (16+ Years) Child (ren) with child (ren) Sibling group A child with medical needs A child with mental health/behavioral needs Please check programs of interest: Connecting Families Resource Parent Meetings and Events Heart to Heart Resource Parent Mentoring Program Resource Parent Speakers Bureau Skills (Please check all that apply): Fundraising Writing/Editing Event Planning Public Speaking Graphic Design Other OtherPlease list any training, expertise or experience in the areas checked off.Have you volunteered with other organizations? If yes, please list:Other Please list your availability Monday Tueday Wednesday Thursday Friday Saturday Sunday Morning Hours: Afternoon Hours: Evening Hours: Please indicate the counties you are willing to travel to: Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Other (Not NJ) Please list three personal (excluding family) or work related references.1. Name First Last 1. Phone1. Type Personal Work 2. Name First Last 2. Phone2. Type Personal Work 3. Name First Last 3. Phone3. Type Personal Work I authorize Foster and Adoptive Family Service (embrella) to contact the references listed above. I agree that the information submitted in this application is true and correct to the best of my knowledge. I understand that volunteer applications for the Connecting Families Heart to Heart Mentoring Program will be reviewed and verified by the Department of Children and Families.* I agree Δ
