Become a Circle Ally

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Today's Date (Month/Day/Year) REQUIRED Please fill out this field. Please enter a date.

Birth Date (Month/Day/Year) REQUIRED Please fill out this field. Please enter a date.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Cell Phone Number with Area Code REQUIRED Please fill out this field. Please enter a phone number.

Other Phone Number with Area Code Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Place of Employment REQUIRED Please fill out this field. Please enter valid data.

Select your preferred method of contact REQUIRED Please fill out this field.

How many children do you have that are 18 years or younger? Please fill out this field.
Child 1
- Age REQUIRED Please fill out this field. Please enter valid data.
- Would attend children’s program? REQUIRED Please fill out this field.
Child 2
- Age REQUIRED Please fill out this field. Please enter valid data.
- Would attend children’s program? REQUIRED Please fill out this field.
Child 3
- Age REQUIRED Please fill out this field. Please enter valid data.
- Would attend children’s program? REQUIRED Please fill out this field.
Child 4
- Age REQUIRED Please fill out this field. Please enter valid data.
- Would attend children’s program? REQUIRED Please fill out this field.

Please list anyone else living in your home and their relation to you.

2024 Federal Poverty Guidelines

Household Size	100% (Poverty Line)	150%	185%	200%
1	$15,060	$22,590	$27,861	$30,120
2	$20,440	$30,660	$37,814	$40,880
3	$25,820	$38,730	$47,767	$51,640
4	$31,200	$46,800	$57,720	$62,400
5	$36,580	$54,870	$67,673	$73,160
6	$41,960	$62,940	$77,626	$83,920
7	$47,340	$71,010	$87,579	$83,920
8	$52,720	$71,010	$97,532	$105440
Add for each additional	$4,720	$7,080	$8,732	$9,440

Live at or below 200% of the Federal Poverty Guidelines? REQUIRED Please fill out this field.

At least 18 years old REQUIRED Please fill out this field.

Speak and read English REQUIRED Please fill out this field.

Able to attend weekly classes or meetings REQUIRED Please fill out this field.

Motivated to learn and apply new ideas REQUIRED Please fill out this field.

Are you willing to build relationships across class and cultural lines? REQUIRED Please fill out this field.

Supported and encouraged by family to participate in Circles REQUIRED Please fill out this field.

Has been in recovery for at least the past 6 months if history of alcohol or other addiction? REQUIRED Please fill out this field.

Relatively stable (not currently homeless, dealing with domestic or drug abuse) REQUIRED Please fill out this field.

What languages do you speak fluently? REQUIRED Please fill out this field. Please enter valid data.

How did you hear about Circles? REQUIRED Please fill out this field. Please enter valid data.

Do you belong to any groups or community organizations? REQUIRED Please fill out this field. Please enter valid data.

What about being an Ally is of interest to you? REQUIRED Please fill out this field. Please enter valid data.

What are your hobbies, interests or passions? REQUIRED Please fill out this field. Please enter valid data.

What are you good at? What are you not so good at? REQUIRED Please fill out this field. Please enter valid data.

What behaviors do you find most frustrating in people? REQUIRED Please fill out this field. Please enter valid data.

What aspect of friendship is the most important to you? REQUIRED Please fill out this field. Please enter valid data.

What would you like us to know about you before we work together? REQUIRED Please fill out this field. Please enter valid data.

Background checks are required for participation in any activities where children may be present. This information also may help Circles to support you better if you are experiencing barriers related to having a record, such as voting rights, housing, and employment.

Have you ever been convicted of a felony? (Yes or No, If yes, please explain.) REQUIRED Please fill out this field.

Do you currently have a court case pending? (Yes or No, If yes, please explain.) REQUIRED Please fill out this field.

Do you have any active warrants? (Yes or No, If yes, please explain.) REQUIRED Please fill out this field.

Emergency contact name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Your Circles chapter name REQUIRED Please fill out this field. Please enter valid data.

Your Circles chapter, legally named above together with Circles USA, (jointly referred to as “Circles”) request that you agree to the following Code of Conduct and Statement of Confidentiality. Please read them and sign below to indicate your agreement with these statements.

CODE OF CONDUCT FOR ALL CIRCLES MEETINGS, ACTIVITIES, AND EVENTS

I will dedicate myself to supporting all participants and volunteers.
I will respect the inherent dignity of every person without regard to their race, ethnicity, creed, age, religion, disability, sexuality, or nationality.
I will be honest and strive to be a person of integrity.
I will follow Circles’ rules and policies for volunteers.
I will not engage in activities which may be seen as a conflict of interest between Circles and myself.
I will contribute to a safe environment by not harming others in any way, whether through discrimination, harassment, exploitation, abuse, or neglect.
During meetings, I will not be under the influence of illegal drugs or alcohol.
If I need to end my commitment to Circles, I will step down considerately and in a way that minimizes disruption to the community.

STATEMENT OF CONFIDENTIALITY

I agree to ensure the confidentiality and privacy of all who participate including Circle Leaders, Allies, volunteers, and staff. I understand that the fact that an individual is served by Circles must be kept confidential, and at no time will I disclose personal information that is shared at Circles meetings.

I understand that Circles maintains a strict policy on the confidentiality of my records. All information I share or which Circles becomes aware of through my involvement will remain confidential and will not be shared with anyone outside of Circles unless I have given my written permission.

I understand that there are some situations where this confidentiality policy becomes void and staff are required by law to release information. These circumstances include: (1) If Circles becomes aware that I may be a danger to myself or others; (2) If Circles become aware of an adult, elder, or child abuse situation taking place; (3) If Circles is under court order to share information.

I Agree Please select this field.

Printed Name REQUIRED Please fill out this field. Please enter valid data.

Signature (By typing your name it is understood to be an electronic signature.) REQUIRED Please fill out this field. Please enter valid data.

Date (Month/Day/Year) REQUIRED Please fill out this field. Please enter a date.

MEDIA RELEASE - ADULT

Your Circles chapter, legally named above, together with Circles USA, (jointly referred to as “Circles”) sometimes use photos and videos of participants and volunteers in social media and promotional materials. Please read the below media release and sign if you agree to these terms.

I grant permission to Circles to use my image (whether photograph or video) in its media publications including emails, brochures, publications, presentations, videos, social media, and websites. I waive any and all rights to inspect or approve of the photographs or media prior to their use. I waive any rights to royalties or compensation arising from use of these images.

Please check all that apply. REQUIRED Yes, Myself No, Myself Yes, My children until they are 18 yrs. old No, My children until they are 18 yrs. old Please fill out this field.

Signature (By typing your name it is understood to be an electronic signature.) REQUIRED Please fill out this field. Please enter valid data.

Date (Month/Day/Year) REQUIRED Please fill out this field. Please enter a date.

Gender REQUIRED Please fill out this field.

Number of People in Household REQUIRED Please fill out this field. Please enter valid data.

Veteran REQUIRED Please fill out this field.

Ethnicity REQUIRED Please fill out this field.

Housing Status REQUIRED Please fill out this field.

Marital Status REQUIRED Please fill out this field.

Highest Level of Education REQUIRED Please fill out this field.

Disabled Member in Household REQUIRED Please fill out this field.

People living in the same household (do not list name from top of form) Please fill out this field.
Member 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Applicant REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Date of Birth and Age REQUIRED Please fill out this field. Please enter valid data.
- Monthly Income Source & Amount REQUIRED Please fill out this field. Please enter valid data.
- Insurance (Medicare/chips/Medicaid/none) REQUIRED Please fill out this field. Please enter valid data.
- College Student REQUIRED Please fill out this field.
- Will they attend children's program? REQUIRED Please fill out this field.
Member 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Applicant REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Date of Birth and Age REQUIRED Please fill out this field. Please enter valid data.
- Monthly Income Source & Amount REQUIRED Please fill out this field. Please enter valid data.
- Insurance (Medicare/chips/Medicaid/none) REQUIRED Please fill out this field. Please enter valid data.
- College Student REQUIRED Please fill out this field.
- Will they attend children's program? REQUIRED Please fill out this field.
Member 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Applicant REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Date of Birth and Age REQUIRED Please fill out this field. Please enter valid data.
- Monthly Income Source & Amount REQUIRED Please fill out this field. Please enter valid data.
- Insurance (Medicare/chips/Medicaid/none) REQUIRED Please fill out this field. Please enter valid data.
- College Student REQUIRED Please fill out this field.
- Will they attend children's program? REQUIRED Please fill out this field.
Member 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Applicant REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Date of Birth and Age REQUIRED Please fill out this field. Please enter valid data.
- Monthly Income Source & Amount REQUIRED Please fill out this field. Please enter valid data.
- Insurance (Medicare/chips/Medicaid/none) REQUIRED Please fill out this field. Please enter valid data.
- College Student REQUIRED Please fill out this field.
- Will they attend children's program? REQUIRED Please fill out this field.
Member 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Applicant REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Date of Birth and Age REQUIRED Please fill out this field. Please enter valid data.
- Monthly Income Source & Amount REQUIRED Please fill out this field. Please enter valid data.
- Insurance (Medicare/chips/Medicaid/none) REQUIRED Please fill out this field. Please enter valid data.
- College Student REQUIRED Please fill out this field.
- Will they attend children's program? REQUIRED Please fill out this field.
Member 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Applicant REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Please fill out this field.
- Date of Birth and Age REQUIRED Please fill out this field. Please enter valid data.
- Monthly Income Source & Amount REQUIRED Please fill out this field. Please enter valid data.
- Insurance (Medicare/chips/Medicaid/none) REQUIRED Please fill out this field. Please enter valid data.
- College Student REQUIRED Please fill out this field.
- Will they attend children's program? REQUIRED Please fill out this field.

Employment Status REQUIRED Please fill out this field.

Total Household Income/Benefits Monthly Amounts

SSDI Please enter valid data.
SSI Please enter valid data.
SNAP/Food Stamps Please enter valid data.
Unemployment Benefits Please enter valid data.
VA Benefits Please enter valid data.
Social Security Benefits Please enter valid data.
Child Support Please enter valid data.
Monthly Earned Income Please enter valid data.
Other Income Please enter valid data.

SNAP Info Provided REQUIRED Please fill out this field.