Young Professionals Board Application

Contact Details

First Name

Last Name

Email Type

Mobile Phone

Opt-In for Text Communication

Yes

Street Address

City

State

Zip Code

Are you or have you been a Willow House Family Member? (i.e. have you attended / signed up for group support services?)

YesNo

Employment

Current Employer

Current Title

Current Job Description

Volunteer with Willow House

How did you hear about Willow House?

Why are you interested in joining the Young Professionals Board at Willow House?

Which traits and skills do you have that you feel will be most helpful in supporting Willow House and it's mission?

Do you have any clinical certifications or degrees? If so, please list each certification and degree with year & location obtained.

Have you ever been convicted of any felonies or misdemeanors other than for minor traffic offenses?

YesNo

If yes, please explain

Any additional comments, concerns, or questions.

Signature

Willow House requires that background checks be completed for all volunteers who are working directly with Willow House children and teens in the program setting. Your signature below indicates your understanding of this volunteer policy and your agreement to your name being submitted for a background check following your completion of the training.

Signature (Type Full Name)

Date

Contact Information