Contact Information

Title
First Name*
Last Name*
Country
State / Province*
Address
City
Email*
Confirm Email*
Phone

Volunteer Information

Please check which volunteer position(s) you are interested in.
  • Dinner Host
  • Volunteer Facilitator
Emergency Contact Name
Emergency Contact Phone
Please tell us your reasons for applying.
How did you hear about Jeff's Place?
Describe your personal, prefessional, and/or volunteer experiences with children, teens, and adults
Describe any previous training you have had related to the grieving process.
Have you had a major loss within the past year?
Whom did you lose?
What was your most significant death loss experience?
Please list any childhood losses
Have you ever been treated for any psychiatric illnesses, alcohol or substance abuse?
Have you ever been charged with, pleaded guilty to, or been convicted of a criminal offense?*
Please list name and contact information for 2 references.
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