Florida Region of NA: Corrections Volunteer Form
Please fill this form out and click submit.  A coordinator will mail you a PDF to print, sign, and scan in and email back.
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Email *
First Name *
Middle Name
Last Name *
Maiden Name
Address where you live (this will be used to match you to an Institution) *
Phone Number *
Date of Birth *
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/
DD
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Race *
Gender *
Drivers License Number *
Drivers License State *
Hair Color *
Eye Color *
Height *
Weight *
Have you ever been arrested on a misdemeanor or felony charge? *
If yes, explain...
Have you ever been convicted on a misdemeanor or felony charge? *
If yes, explain...
Do you have a relationship (for example parent, spouse, friend, etc) or are you currently on the visitation list of anyone incarcerated? *
If yes, give the inmate’s name, DC#, and your relationship to the inmate.
Have you ever worked for the Florida Department of Corrections? *
If yes, please indicate where and when you were employed.
Do you have any relatives working for the Department of Corrections? *
If yes, please provide the relative's name, your relationship to them, and their work location.
Please provide an emergency contact name and phone number. *
Submit
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