Darrell Gwynn Foundation

Contact Information
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- First name *
  
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Personal Information
- Date of Birth *
  
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Disability Information
- Type of Disability *
  
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  Date of Disability *
  
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  Level of Injury *
  
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Background Data
- Previous Speaking Experience *
  
  What kind of transportation do you use? *
  
  What do you use to get around? (ex: power chair, manual chair, walker etc.) *
  
  List any foreign languages you speak *
  
  What counties can you seve? *
  
  Times & Days Available *
  
  Hobbies and Interests *
  
  List any information that may be helpful in your presentations. (ex: Personal Outlook, medical complications. etc. ) *
  
  Have you ever been convicted of a felony or a 1st degree misdemeanor? *
  
  Yes No
  
  If yes please explain when, where and what charges *
  
  Have you ever pled nolo contendre or pled guilty to a crime which is a felony or first degree misdemeanor? *
  
  Yes No
  
  If yes please explain when, where and what charges *
  
  Have you ever had the adjudication withheld for a crime which is a felony or first degree misdeameanor *
  
  Yes No
  
  If yes please explain when, where and what charges *
  Note: A "yes" answer to these questions will not automatically bar you from serving as a speaker
  for the Darrell Gwynn Foundation.
  
  The nature, severity, number (if more than one), and date of offence in relation to the position for
  which you are applying is considered.
  
  If accepted as a speaker for the Darrell Gwynn Foundation's Education & Prevention Program,
  you will be required to:
  
  Work under the supervision of the Program Coordinator.
  
  Attend training sessions and refresher classes as required.
  
  Accept the program guidelines and limitations.
  
  Submit to a criminal background check.
  
  Submit a report on your progress, using the forms provided.

VOLUNTEER SPEAKER APPLICATION (Team Spokesman Only)