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Clark County Circles™

Ally Interest Survey

Contact Information
Name:
Address:
Home Phone: Work Phone:

Availability (check all that apply)
Weekday mornings Weekend mornings Best time to contact:
Weekday afternoons Weekend afternoons AM PM
Weekday evenings Weekend evenings  

Rank Your Interest Levels
Ally: Financial
Ally: Educational/Employment
Ally: Social/community building

Background Information

1) Summarize skills, qualifications, and or training you have acquired from
employment, education, life experience or through activities, including hobbies
or sports.

2) List community/social/faith-based groups you are involved with that you
may be able to share with a participant.


Please answer the following questions:

What about being an Ally is of interest to you?

What would you like a Circle Leader to know about you before
being matched?

What behaviors do you find most frustrating in people?

I would be really good at:

I would not be so good at:

Have you ever been convicted of a crime?

Yes: No:

If yes, please explain:


Person to Notify in Case of Emergency
Name:
Address:
Home Phone:
Work Phone:

Agreement and Confidentiality Statement

As a volunteer of Think Tank I understand that I must ensure the
confidentiality and privacy of the participants we serve. I further
understand that even the fact an individual is served by Think Tank
must be kept private and confidential, and at no time shall I disclose
this or any other information.

Signature:

Date:

Survey form creation donated by VirginiaDesignsForYou.com

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