Montgomery County Emotional Spiritual Care Volunteer (ESCV) Application Form
Thank you very much for your interest in becoming an Emotional Spiritual Care Volunteer with Montgomery County, Maryland! Below are some of the many skills we will need to develop and operate our team. Please mark the activities with which you would like to help and provide your background information. The quality of your application will inform your selection to participate in the training cohort on June 15, 2017.
First Name *
Your answer
Last Name *
Your answer
Organization & Title *
Your answer
Email Address *
Your answer
Street Address *
Your answer
Apt or Suite # *
Your answer
City/State/Zip Code *
Your answer
Phone (Work) *
Your answer
Phone (Personal)
Your answer
Phone (Other)
Your answer
Please briefly explain why you would like to become an ESCV? *
Your answer
Do you have a minimum of 20hrs/year to dedicate to your duties as an ESCV? *
What are the resources in your community that you can draw on for this program? *
Your answer
Are you comfortable counseling people of other faiths, or no religious affiliation, with acceptance, respect, and free from judgment or proselytizing? *
The following religious leader/supervisor can provide an endorsement for me to become certified as an ESCV (this can be provided in the form of a letter or an email)
Full Name *
Your answer
Organization and Title *
Your answer
Address *
Your answer
Email address *
Your answer
Phone number *
Your answer
Please list any applicable courses or certifications you have completed for your work performed as a religious leader, mental health counselor or social worker. This includes having practiced emotional and/or spiritual care of others (this can include pastoral care or youth mentoring).
Courses the applicant may have taken: *
Name of Institution *
Your answer
Date *
Your answer
Course or Certification *
Your answer
Please list the last three years of your experience in providing counseling services as a clergy member, religious leader, mental health counselor or social worker. This includes having practiced emotional and/or spiritual care of others (this can include pastoral care or youth mentoring).
Name of Organization *
Your answer
Date Served *
Your answer
Type of Care Provided *
Your answer
Language abilities (including American Sign Language):
Native Language *
Your answer
Language 1 *
Your answer
Language 2 *
Your answer
Language 3 *
Your answer
Summarize your volunteer experience:
Number of years (total): *
Your answer
Organization Name: *
Your answer
Types of activities performed: *
Your answer
Additional information: *
Your answer
List two references from your volunteer work or personal reference:
Name of first reference *
Your answer
Phone *
Your answer
Email *
Your answer
Name of second reference *
Your answer
Phone *
Your answer
Email *
Your answer
In order to receive a Certification as an ESCV, a Criminal Background Check will be required of those who complete the training. Each participant is also expected to complete the FEMA online course, IS-00100.b - Introduction to Incident Command System - ICS-100
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