Employment / Volunteer Application

Please Fill in the Following Fields

Maiden Name:
Date of Birth:
Daytime Phone:
Evening Phone:
Are you Applying for:
Are you Currently Attending High School:
What Year Will you Graduate From High School?:
Did you Graduate from High School?:
What Year Did You Graduate From High School?:
Did you Earn a Diploma or A GED?
Are You Currently Attending College?:
What Year Will You Graduate From College?:
What Degree Will You Earn:
Did You Graduate from College?:
What Year Did you Graduate From College?:
What Degree do you Hold?:
1 Employer Address:

Employment History

Employer #1

Complete form for at least 1 Employer

1 Place of Employment:
1 Employer Contact:
1 Employer Phone:
Reason for Leaving Employer 1:

Employment History

Employer #2

This Employer is Optional, You may select Next to Skip

2 Place of Employment:
2 Employer Address:
2 Employer Contact:
2 Employer Phone:
2 Reason for Leaving:

Employment History

Employer #3

This Employer is Optional, You may select Next to Skip

3 Place of Employment:
3 Employer Address:
3 Employer Contact:
3 Employer Phone:
3 Reason for Leaving:


Enter 3 References along with their phone numbers

1 Reference Name:
1 Reference Phone:
2 Reference Name:
2 Reference Phone:
3 Reference Name:
3 Reference Phone:

Finalize and submit your application by reading the agreement, electronically signing below and clicking the SUBMIT Button

NON-DISCRIMINATION: The Family Healing Center, Inc. (FHC) does not discriminate against any person in the provision of services or in any other manner on the grounds of race, color, ethnicity, creed, religion, sex, national origin, sexual orientation, gender identity, citizenship, marital status, familial status, ancestry, age, disability or veteran status. If you feel like you have been discriminated against by FHC, please contact the Executive Director immediately at 606.548.1502.

CONFIDENTIALITY/PERMISSION STATEMENT: By signing below, I hereby state that all of the information on this application is true, correct and complete to the best of my knowledge. I also give FHC the right to check my criminal background information. I hereby agree to assure the confidentiality of other program participants and applicants at FHC. I understand and agree that my application and file may be reviewed by FHC funders and any other funders who have a legitimate interest.

I Agree
Applicants Electronic Signature