Refuge 139 Application 2018
Before you begin:
We take Child Safety very seriously. In order to participate in this program, the applicant must not have intentionally viewed pornography for a minimum of 12 months and must pass a Criminal Background Check to qualify. If you have been convicted of child abuse, you will be disqualified from volunteering with JAARS and the Refuge 139 program. If you would like clarification about these before proceeding, please email refuge139_director@jaars.org.
Please list your First, Middle, and Last names as they appear on your Passport.
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Preferred Name
Your answer
Date of Birth
mm/dd/yyyy
Your answer
Male or Female
Address Line 1
Your answer
Address Line 2
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Email Address
Your answer
Primary Phone
Your answer
Secondary Phone
Your answer
Skype Name
Your answer
How did you hear about Refuge 139?
Your answer
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