I would like to be considered for participation in the CIRCLES' Program as a/an: *

Participant/Champion for Change

Ally

I am willing to meet with the program staff to discuss this application. *

Yes

Regarding admission into the program, I understand that the program staff may say YES, NO, or NOT YET. *

Yes

I am willing to undergo a background check. *

Yes

I am able and willing to set aside Wednesday nights from 5:30- 7:30 pm to participate in this program. *

Yes

I am able and willing to commit 18-36 months to this program. *

Yes

Race *

American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

White

More than One Race

Other/Unknown

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Birthday *

MM

DD

YYYY

Language(s) Spoken *

Select all that apply

Fluent English

Fluent Spanish

Limited English

Limited Spanish

Relationship Status *

Single

Domestic Partnership

Married

Widowed

Divorced

Other Relationship Status (please add details below)

Highest Level of Education *

Did not graduate from High School

High School Degree or Equivalent

Vocational Training

Associate Degree

Bachelor Degree

Postgraduate Degree

Childhood Class Category *

Reflect back on your experiences in your early formative years, and think about your experience now. What points along the class continuum would you say best represent your experiences?

Generational Poverty

Situational Poverty

Lower Middle Class

Middle Class

Upper Middle Class

Wealthy (1st Generation)

Wealthy (Multi-Generation)

Current Class Category *

Reflect back on your experiences in your early formative years, and think about your experience now. What points along the class continuum would you say best represent your experiences?

Generational Poverty

Situational Poverty

Lower Middle Class

Middle Class

Upper Middle Class

Wealthy (1st Generation)

Wealthy (Multi-Generation)

Are you currently receiving public assistance? *

Yes

No

• Do you have issues concerning your mental health? *

Yes

No

• Do you have any issues concerning substance abuse?

Yes

No

Chemical Dependency *

Do you have any reservations about being matched with a program participant who has had issues with chemical dependency? Note: Participants must be in recovery from dependency and must have achieved stability.

No

Yes

Mental Health *

Do you have any reservations about being matched with a program participant who has had issues with mental health? Note: Participants must be in treatment for mental health and must have achieved stability.

No

Yes

Jail or Prison *

Do you have any reservations about being matched with a program participant who has been in jail or prison?

No

Yes

Race or Ethnicity *

Do you have any reservations about being matched with a program participant who is a different race or ethnicity?

No

Yes

LGBTQ+ *

Do you have any reservations about being matched with a program participant who is member of the LGBTQ+ community?

No

Yes

Gender *

Do you have any reservations about being matched with a program participant who is not the same gender as you?

No

Yes

Acceptance into C.I.R.C.L.E.S *

I understand that, if admitted to the program, my eligibility to continue in the program at any time thereafter will be at the discretion, and according to the terms, of the program staff

I agree

Meeting Attendance *

Participants and Allies are expected to attend a minimum of 75% of the meetings each month.

I agree

Inform when Cannot Attend *

I will inform the coach or program manager when I am not able to be present at a weekly meeting.

I agree

Phase II Attendance *

I am willing to meet in matched groups outside of weekly C.I.R.C.L.E.S. programming at least once per month in Phase II (Approximately 18-24 months).

I agree

N/A