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TIP Volunteer Registration

To submit your Volunteer Application, complete and submit this form. Upon submission, you will be directed to a confirmation page where you can submit the $45 Registration Fee with PayPal. If you prefer, you can mail the registration fee to Trauma Intervention Programs c/o Mandy Atkission, 159 High Ridge Dr., Mills River, NCĀ  28759 Please contact us if you have any questions.
* denotes required field  
*Name:    
*Home Address: Check box if mailing address different
*City:
*State: *Zip Code:
Mailing Address:  
Mailing City:
Mailing State: Mailing Zip Code:
*Home Phone:    
Work Phone:    
*Cell Phone: *Cell Carrier:
*Email: Fax:
*Birth Date:    
Employer:  
*Occupation:  
Special Skills/Training:
Types of Volunteer duties you are willing to assume (check all that apply)
Emergency Services Work    Social Media    Clerical    Fundraising    Other
If Other, please describe:
*Have you had previous volunteer experience?  
If Yes, where?
Describe duties:
How did you hear about TIP?
*Do you have any allergies, physical limitations, or other health issues that are important for us to know?  
If yes, please describe:
*Are you volunteering for school credit?  
Why do you want to
be a TIP volunteer?
*Have you experienced a traumatic incident in your life?  
If so, when?    
If yes, please explain:
References: Give three references, not related by blood or marriage, who are responsible adults of reputable standing in their community, all of whom you have known you for at least 3 years.
Reference 1
*Complete name: *Years known:
*Address
(include City, State & Zip)
*Phone: Email:
Reference 2
*Complete name: *Years known:
*Address
(include City, State & Zip)
*Phone: Email:
Reference 3
*Complete name: *Years known:
*Address
(include City, State & Zip)
*Phone: Email:
Emergency contacts: Please provide three people to contact in case of an emergency.
*Name: *Relationship:
*Phone Number:    

*Name: *Relationship:
*Phone Number:    

*Name: *Relationship:
*Phone Number:    

*Have you ever been convicted of a crime?     No Yes
If yes, please explain and provide date, charge, and other pertinent details:
*Do you have any traffic violations in the last 10 years?     No Yes
If yes, please explain:
North Carolina Law requires that motor vehicle owners be covered by automobile liability insurance. Please provide the following information:
*Insurance Carrier: *Policy Number:
* I hereby affirm that the answers and statements provided in this application are true and correct.
* Please enter the characters exactly as they appear