Ally application

Circles Ally Application

Circles offers a unique partnership of Circle Leaders, each matched with 2-3 Circle Allies (coaches). A Circle Leader is a person and family members, currently earning below 200% of the federal poverty level (see table on page 2), and committed to improving their quality of life through livable wage employment and self-sufficiency. Circle Allies are life coaches that serve Circle Leaders as encouragers and bridges to social and economic wellbeing. Circles mission is to inspire, inform, and equip individuals, families, and community to resolve poverty and thrive.
Name

First

Last
Email Address
Age
Address
City
State
Zip
Phone Number
May we leave a message at the above number?
Preferred Method of Contact
Please check all that apply:

Live at or above 200% of the Federal Poverty Guidelines At least 18 years old Able to attend weekly classes or meetings Motivated (interested in) learning and applying new ideas If there is a history of alcohol or other addiction, you have been in recovery for at least the past 6 months (Comment at bottom page if you wish) Not currently un-housed (homeless), having a current place of residence. Currently not encountering domestic abuse Willing to build intentional relationships across class and cultural lines
Please provide additional household names and ages
Summarize skills, qualifications, and or training you have acquired from employment, education, life experience, or through activities, including hobbies or sports. Passions and talents you would like to share with others:
Summarize skills, qualifications, and or training you have acquired from employment, education, life experience, or through activities, including hobbies or sports. Passions and talents you would like to share with others:
Please tell us where you heard about Circles. *
What behaviors do you find most frustrating in people? *
What would you like a circle leader to know about you before you are being matched? *
I am really good at: *
I am not so good at: *
Have you ever been convicted of a felony? A felony or other conviction will not automatically exclude you from participating in Circles Ashland. Background Checks are a requirement because children may be present during Circles meetings. Children will be supervised by their parents during meals and under the care of screened childcare providers while Circle Leaders are in meetings.
Currently, are there any pending court cases in which you are involved?
Emergency Contact

First

Last
Relationship
Phone Number
Please add any additional comments:
Agreement and Confidentiality Statement As a participant of Circles I understand that I must ensure the confidentiality and privacy of all those who participate including Allies, volunteers, and staff. I further understand that the fact an individual is served by Circles must be kept private and confidential, and at no time shall I disclose personal information that is shared in Circles.

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Date / Time

Ally application

Circles Ally Application