Volunteer Form (Online Application)

Directions: Complete the online application below.

If you have received shelter or services/assistance (including support groups) from any domestic violence agency or, if you have been a domestic violence victim within the past year, please contact the Direct Services/Outreach Director (910.343.9969 ext. 111) before completing this application.

Volunteer Training Dates: TBA (Volunteer Application required):

This agency does not discriminate on the basis of race, color, religion, age, gender, national origin, political affiliation, sexual identity, or other non-performance factors. All volunteer assignments are at the discretion of the management of Domestic Violence Shelter and Services, Inc.


E-mail Address

Confirm E-mail Address



Days and Hours Available To Volunteer:





Home Phone

Work Place


Purpose in Volunteering

Hobbies or Interests

How did you discover the opportunity to become an advocate/volunteer

Below is a list of possible volunteer activities, please check the ones you would be interested in

Other (specify)

Past Relevant Experience

What qualities and skills do you have that you feel would contribute in this type of work:

What are your feelings toward a woman who elects to remain in a violent situation:

Often children from violent homes repeat behavior they have witnessed (i.e. verbal and physical abuse). Describe your reaction toward a child who may chose to repeat aggressive behaviors in your presence:

Any comments or questions

Have you ever been convicted of a criminal offense

If yes, please give a detailed description of the criminal offense

Please list two (2) references (Name, Address, Relationship, Home/Work Phone):

Reference #1

Reference #2

Please provide emergency contacts: (Name, Address, Relationship, Home/Work Phone):

Person #1

Person #2

I certify that the above statements are true and correct to the best of my knowledge and belief. I understand that willful misrepresentation or omission of facts may prevent my serving as a volunteer. I release all persons and agencies from any and all liability which may be incurred as a result of obtaining and using this information.