Counselor Application Personal Information

Counselor Application
Personal Information
Name: _____________________________________________ Date: _________
Street Address: _______________________________________________________
City: ________________________ State: ______ Zip: _______________
Home phone: ______________
Work phone: ______________
Social Sec. #: _________________________________ Date of Birth ___/___/___
Employment History
Please provide employment information for the past five years, with most recent position held
first. If more space is needed use an extra sheet of paper.
Employer: _________________________________________________
Street Address: ________________________________________________
City: ________________________
State: ______
Zip: _______________
Supervisors Name: ______________________________ Title: ___________________

Phone: _____________________ Dates of Employment: __________ to_________
Position Held: __________________________________________________
-----------------------------------------------------------------------------------------------------------Employer: _________________________________________________
Street Address: ________________________________________________
City: ________________________
State: ______
Zip: _______________
Supervisors Name: ______________________________ Title: ___________________

Phone: _____________________ Dates of Employment: _________ to ___________
Position Held: __________________________________________________
------------------------------------------------------------------------------------------------------------
PO Box 372 North Hollywood, CA 91603

Info@peacockfoundation.org www.peacockfoundation.org
(818) 763-1072
Application Questions
Please answer all of the following questions as completely as possible. If more space is
needed, use an extra sheet of paper or write on the back of this page.
1. Why do you want to become a counselor with Peacock Foundation?
2. Do you have any previous experience volunteering or working with animals/youth? If so,
please specify.
3. What qualities, skills, or other attributes do you feel you have that would be beneficial?
Please explain.
4. Describe your general health. Are you currently under a physicians care or taking any
medications? If so, please explain.

(818) 763-1072
5. How would you describe yourself as a person?
6. How would your friends, family, and co-workers describe you?
7. Are you willing to communicate regularly and openly with program staff, attend weekly
supervision, and receive feedback regarding any difficulties during your participation in
the program?
8. Are you willing to attend two 2-hour training sessions before you are placed?

(818) 763-1072
Please read this carefully before signing:

The Peacock Foundation Counseling Program appreciates your interest in becoming an intern.
Please initial each of the following:
_______ I agree to follow all program guidelines and understand that any violation will result in
suspension and/or termination of the internship.
_______ I understand that The Peacock Foundation is not obligated to provide a reason for their
decision in accepting or rejecting me as a counselor.
_______ (optional) I agree to allow The Peacock Foundation to use any photographic image of
me taken while participating in the intern program. These images may be used in promotions or
other related marketing materials.
I understand I must return all of the following completed items along with this application, and
that any incomplete information will result in the delay of my application being processed:
Copy of your valid drivers license
Information Release Form
Personal References Form
Interest Survey Form
Copy of current Intern Registration from BBS
Copy of current Liability Insurance coverage
By signing below, I attest to the truthfulness of all information listed on this application and agree
to all the above terms and conditions.
_________________________________________________ ________________
Signature
Date
Please return or mail this application and the items listed above to Program Coordinator, The
Peacock Foundation, PO Box 372, North Hollywood, CA 91603.

(818) 763-1072
Information Release
I, _________________________________________, understand it will be necessary for The
Peacock Foundation to conduct a background check regarding my criminal history, personal
references, and employment.
I authorize The Peacock Foundation to obtain any needed information regarding my
legal/criminal history, character references, and employment from any state or federal agency, my
employer, and personal references for the purposes of participating in a counseling/internship
program. Further, I provide permission for The Peacock Foundation to conduct the same
investigation of my background in previous states in which I have resided.
Further, I understand that information about myself will be anonymously (without my name)
shared with prospective facility partners to aid in determining a suitable match. Once a
counselor/facility match is determined, my identity and any other information known about me
may be shared with the facility to ensure and aid in facilitating a safe and successful match
relationship.
____________________________________________ _______________
Signature
Date
Full Name________________________________________________________
Address______________________________ City_____________ State____ Zip_____
Date of Birth ______/_____/________
Social Security Number________/_______/________
Current Drivers License No.___________________ State: __________
Please list any other cities, states, and dates of residency during the past 10 years.
______________________________ _____________________
City State
From (m/year) To (m/year)
______________________________ _____________________
City State
______________________________ _____________________
City State
______________________________ _____________________
City State
(818) 763-1072
Personal References
Please list the names, addresses, and phone numbers of three people you would like to use as
character references (only people you have known for at least a year). Include at least one
relative. Any information The Peacock Foundation gathers from these references will be held as
confidential and not released to you, the applicant.
Relatives Name: _____________________________________
Address: __________________________________________
City: ________________________
State: ________________ Zip: _________
Phone: ______________________________ Relationship: ____________________

How long known: ___________________
Previous/Current Supervisors Name: ______________________________________________
Address: ___________________________________________
City: _______________________ State: ________________ Zip: __________
Phone: _____________________________ Relationship: ____________________
How long known: ___________________
Name: ___________________________________________________________
Address: __________________________________________
City: _____________________
State: ________________ Zip: ____________
Phone: _______________________Relationship: ____________________

How long known: ___________________

(818) 763-1072
Counselor Interest Survey

Name: ____________________________________________ Date: __________
Please complete all the following. This survey will help The Peacock Foundation know more
about you and your interests and help us find a good match for you.
What are the most convenient times for you to work at a facility? Please check all that apply.
Weekdays: ___ Lunchtime: ___ After school: ___ Evenings: ___ Weekends: ___
Please indicate age group(s) and/or you are interested in working with:
Age : ___ 7-10 __1114 ___1518 ___1921 Ethnicity: _______________
Do you speak any languages other than English? If so, which languages?
Do you have fear associated with any of the following animal species?
____Small Mammals
____Reptiles (snakes, lizards, turtles, tortoises)
____Insects
____Arachnids
Would you be willing to work with a child who has disabilities? If so, please specify disabilities
you would be willing to work with and have training in.
What are some favorite things you like to do with other people? What are your favorite subjects to
read about? What is your job and how did you choose this field? What is one goal you have set
for the future?
If you could learn something new, what would it be? What person do you most admire and why?

(818) 763-1072

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Counselor Application

Work phone: ______________

Social Sec. #: _________________________________ Date of Birth ___/___/___

Supervisors Name: ______________________________ Title: ___________________

Supervisors Name: ______________________________ Title: ___________________

PO Box 372 North Hollywood, CA 91603

PO Box 372 North Hollywood, CA 91603

5. How would you describe yourself as a person?

6. How would your friends, family, and co-workers describe you?

PO Box 372 North Hollywood, CA 91603

Please read this carefully before signing:

PO Box 372 North Hollywood, CA 91603

State: ________________ Zip: _________

Phone: ______________________________ Relationship: ____________________

State: ________________ Zip: ____________

Phone: _______________________Relationship: ____________________

PO Box 372 North Hollywood, CA 91603

Counselor Interest Survey

PO Box 372 North Hollywood, CA 91603

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Social Sec. #: _______________________________ Date of Birth _/_/_

Supervisors Name: ____________ Title: _

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State: ________ Zip: _

Phone: __________ Relationship:

State: ____ Zip:

Phone: ___Relationship: