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Trauma-Informed Community Resource Training Volunteer Agreement Form

All information will remain confidential and on file with Hesed Place unless otherwise stated in writing by the applicant.

1. Name (First and Last) *This question is required.

2. Profession

3. Specialty

4. Cell Phone

5. Home Phone

6. Work Phone

7. Email Address

8. Home Address

9. City, State *This question is required.

10. Zip Code

11. What is the best way to reach you? *This question is required.

Text
Cell Phone
Home Phone
Email
Work Phone

12. Volunteer Statement: *This question is required.

I am volunteering to participate in the “Trauma-Informed-Training” Prerequisite Course with Hesed Place. This will be completed as a standard of care amongst various professionals so that services and at will assistance might be offered in order to maximize transdisciplinary care for trauma survivors. If I am unable to attend the session to which I committed, I will provide 48 hour cancellation notice.

13. Consent:

I would like my practice, business, or organization spotlighted and/or promoted by Hesed Place. (Some organizations may be represented as a whole ie. Church, Nonprofit, etc.)
I give consent to community training or other Hesed Place function photographs in which I am participating to be placed on social media or other media modalities (brochures, advertisements, etc)

14. Signature of Consent *This question is required.

Clear

Sign name using mouse or touch pad

Signature of

15. Would you like to be added to our email and/or mailing list? *This question is required.

Yes, my email address is Please enter an 'other' value for this selection.
Yes, my mailing address is Please enter an 'other' value for this selection.
No

16. Please tell us how you would like your name to appear on your Trauma Informed Care Training Certificate? *This question is required.