Circles Ally Application - Cuidando Los Niños

Full Name

Today's Date

Date Of Birth

Address

Cell Phone Number With Area Code

Other Phone Number With Area Code

Email Address

Place of Employment

Preferred Method Of Contact

Cell Phone Text Message Email Other Phone Number

Please list your children (age 18 and under) and if they will attend Children's program

Please list anyone else living in your home and their relation to you.

2024 Federal Poverty Guidelines

2024 Federal Poverty Guidelines
Household Size	100% (Poverty Line)	150%	185%	200%
1	$15,060	$22,590	$30,120	$37,650
2	$20,440	$30,660	$40,880	$51,100
3	$25,820	$38,730	$51,640	$64,550
4	$31,200	$46,800	$62,400	$78,000
5	$36,580	$54,870	$73,160	$91,450
6	$41,960	$62,940	$83,920	$104,900
7	$47,340	$71,010	$94,680	$118,350
8	$52,720	$79,080	$105,440	$131,800
Add for each additional	$5,380	$8,070	$10,760	$13,450

Is your household income above 200% of the Federal Poverty Level, or are you retired and financially stable?

At least 18 years old

Speak and read English

Able to attend weekly classes or meetings

Motivated to learn and apply new ideas

Are you willing to buildrelationships across class and culture lines

Supported and encourages by family to participate in Circles

Has been in recovery for at least the past 6 months if history of alcohol or other addiction

Relatively Stable (not currently homeless, dealing with domostice or drug abuse)

What languages do you speak fluently?

How did you hear about Circles?

Do you belong to any groups or community organizations?

What about being an Ally is of interest to you?

What training or skills would you like to have?

What are your hobbies, interests, or passions?

What are you good at? What are you not so good at?

What behavior do you find most frustrates you the most in people?

What aspect of friendship is the most important to you?

What would you like us to know about you before we work together?

Background

Background checks are required for participation in any activities where children may be present. This information also may help Circles to support you better if you are experiencing barriers related to having a record, such as voting rights, housing, and employment.

Have you ever been convicted of a felony? Yes or No. If Yes please explain

Do you currenlty have court cases pending? Yes or No. If Yes please explain

Do you have any active warrants? Yes or No. If Yes please explain

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Address

Code of Conduct

Your Circles chapter, legally named Circles South Valley, together with Circles USA, (jointly referred to as “Circles”) request that you agree to the following Code of Conduct and Statement of Confidentiality. Please read them and sign below to indicate your agreement with these statements.

CODE OF CONDUCT FOR ALL CIRCLES MEETINGS, ACTIVITIES, AND EVENTS

I will dedicate myself to supporting all participants and volunteers.
I will respect the inherent dignity of every person without regard to their race, ethnicity, creed, age, religion, disability, sexuality, or nationality.
I will be honest and strive to be a person of integrity.
I will follow Circles’ rules and policies for volunteers.
I will not engage in activities which may be seen as a conflict of interest between Circles and myself.
I will contribute to a safe environment by not harming others in any way, whether through discrimination, harassment, exploitation, abuse, or neglect.
During meetings, I will not be under the influence of illegal drugs or alcohol.
If I need to end my commitment to Circles, I will step down considerately and in a way that minimizes disruption to the community.

Statement of Confidentiality

STATEMENT OF CONFIDENTIALITY

I agree to ensure the confidentiality and privacy of all who participate including Circle Leaders, Allies, volunteers, and staff. I understand that the fact that an individual is served by Circles must be kept confidential, and at no time will I disclose personal information that is shared at Circles meetings.

I understand that Circles maintains a strict policy on the confidentiality of my records. All information I share or which Circles becomes aware of through my involvement will remain confidential and will not be shared with anyone outside of Circles unless I have given my written permission.

I understand that there are some situations where this confidentiality policy becomes void and staff are required by law to release information. These circumstances include: (1) If Circles becomes aware that I may be a danger to myself or others; (2) If Circles become aware of an adult, elder, or child abuse situation taking place; (3) If Circles is under court order to share information.

Applicant Signature

Date

Media Release

Your Circles chapter, legally named Circles South Valley, together with Circles USA, (jointly referred to as “Circles”) sometimes use photos and videos of participants and volunteers in social media and promotional materials. Please read the below media release and sign if you agree to these terms. I grant permission to Circles to use my image (whether photograph or video) in its media publications including emails, brochures, publications, presentations, videos, social media, and websites. I waive any and all rights to inspect or approve of the photographs or media prior to their use. I waive any rights to royalties or compensation arising from use of these images.

Myself

My children until they are 18 years old

Signature

Date